Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Would you like your weight to be different?
*
Yes
No
Still Unsure
If so, what would you like to be different?
What is your current weight?
What is your ideal weight?
Place of Birth & Birthdate
Relationship Status:
Single
Married
Widowed
Engaged
Where do you currently live?
Children:
1
2
3
4
5
5+
Pets:
1
2
3
Mini Zoo
Farm
What is your current occupation/career?
Please list your main health concerns:
Other lifestyle concerns and/or goals?
At what point in your Life did you feel your best?
Any serious illnesses/injuries/hospitalizations?
How is/was your Mother's health?
How is/was your Father's health?
What is your ancestry?
What is your blood type?
How is your sleep?
How many hours do you sleep undisturbed?
If you wake up at night, how many times?
What causes you to wake at night?
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain:
Do you take any medications or supplements? Please list ALL:
Any healers, helpers or therapies with which you are currently involved? Please list:
What role does exercise, activity or sports play in your life?
What foods did you eat often as a child?
List Breakfast, Lunch, Dinner, Snacks and Beverages.
What is your food like now?
List Breakfast, Lunch, Dinner, Snacks and Beverages.
Will Family and/or Friends be supportive of your desire to make lifestyle and/or food changes?
Yes!
No.
I'm not sure?
Do you cook?
Every day
Sometimes
Never
I'm a Pro Reservation Maker
What percentage of your food is home cooked?
Where do you get the rest of your food from?
Do you crave sugar, coffee, alcohol, cigarettes, or have any other major addictions?
The most important thing I should do to improve my health is:
Anything else you would like to share with your Health Coach?
