Specialty: Healthcare Assistant
Initial Health Coaching Assessment
Presenting Goals:
The client, Ms. Sarah Jenkins, expressed a primary goal of improving her overall energy levels and managing her pre-diabetes diagnosis more effectively. She is highly motivated to make lifestyle changes to avoid progressing to Type 2 Diabetes and hopes to achieve a sustained increase in vitality through coaching.
Health and Lifestyle Overview:
Ms. Jenkins currently consumes a diet high in processed foods and sugary drinks, with infrequent home-cooked meals. Her movement consists primarily of short walks, averaging 20 minutes, three times a week. Sleep patterns are irregular, with reported difficulty falling asleep and frequent awakenings, leading to an average of 5-6 hours of sleep per night. Stress levels are elevated due to work demands and family commitments. Hydration is inconsistent, with her often forgetting to drink water throughout the day, preferring coffee or fizzy drinks. Screen time is significant, extending to several hours in the evening before bed, primarily on a tablet or smartphone.
Health History and Context:
Ms. Jenkins self-disclosed a recent diagnosis of pre-diabetes and a family history of Type 2 Diabetes. She is not currently on any prescribed medications. Socially, she is a single mother of two school-aged children, which often impacts her ability to prioritise her own health needs. She works full-time in an administrative role that requires prolonged sitting.
Readiness and Barriers:
Ms. Jenkins appears to be in the preparation stage of change, having actively sought out health coaching. Her self-efficacy is moderate, as she believes she can make changes but feels overwhelmed by where to start. Identified barriers include lack of time due to work and family, financial constraints limiting access to healthier food options, and a lack of consistent motivation after previous failed attempts at lifestyle modification.
Initial Plan:
The immediate focus areas will include gradual dietary adjustments, starting with increasing vegetable intake and reducing sugary beverages. We will explore incorporating short bursts of movement into her workday and establishing a consistent bedtime routine to improve sleep hygiene. Ms. Jenkins will be provided with resources on low-cost healthy meal preparation and stress management techniques. The frequency of coaching will be bi-weekly for the first month, transitioning to monthly thereafter, with check-ins via text message in between sessions.
Date: 1 November 2024
Presenting Goals:
[document client's stated goals, motivation for change, and what they hope to achieve through coaching] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in full sentences.)
Health and Lifestyle Overview:
[record current habits around nutrition, movement, sleep, stress, hydration, and screen time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in full sentences.)
Health History and Context:
[note relevant self-disclosed health history, medications, diagnoses, and social factors impacting health] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in full sentences.)
Readiness and Barriers:
[comment on client's stage of change, self-efficacy, and barriers to progress discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in full sentences.)
Initial Plan:
[outline immediate focus areas, lifestyle adjustments, resources to explore, and frequency of coaching] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in full sentences.)