Name
*
First Name
Last Name
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Age
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Date of Birth
*
MM
DD
YYYY
Time of Birth
Hour
Minute
Second
AM
PM
Place of Birth
*
Please indicate your cultural/ethnic background:
Would you like your weight to be different?
*
Select one
YES
NO
If YES, what would your goal weight be and why?
Relationship status
*
SINGLE
MARRIED
DIVORCED
DATING
IT'S COMPLICATED
Do you have children?
*
Do you have pets?
*
Occupation
*
Hours of work per week
*
Please list your main health concerns
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At what point in your life did you feel your best?
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Please list and explain any serious illnesses, hospitalizations or injuries
How is/was the health of your mother?
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How is/was the health of your father?
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What is your ancestry?
What is your blood type?
How is your sleep?
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GREAT
GOOD
OKAY
BAD
REALLY AWFUL
Do you wake at night?
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YES
NO
How many hours of sleep do you get on average?
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Any pain, stiffness, or swelling?
*
Any constipation, diarrhea, gas or digestive issues?
*
Any allergies or sensitivities? If so, please explain.
*
Are your cycles regular?
YES
NO
SOMETIMES
How many days does your cycle last?
Are your cycles painful or symptomatic? Please explain.
Are you currently trying to get pregnant?
Have you reached or are approaching menopause?
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain.
Do you take any supplements or medication? Please list.
*
Do you have any therapists, healers, coaches with which you are involved? Please list.
What role do sports and exercise play in your life? Please explain.
*
What foods did you eat often as a child?
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Please provide as many examples of breakfast, lunch, dinner as well as snacks and beverages as you can.
What is your food like these days?
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Please provide as many examples of breakfast, lunch, dinner as well as snacks and beverages as you can.
Do you cook?
*
YES
NO
What percentage of your food is home-cooked?
*
Where do you get the rest of your food from?
Do you crave sugar, coffee, cigarettes, or struggle with any other addictions?
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What are 3 things that you can't currently stop feeling stressed or overwhelmed by?
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What would you do if you could do anything in the world?
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What are you most afraid of and why?
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Do you have any dreams you've given up on? If so, explain.
*
What are the things you believe are stopping you from living your best life?
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Please briefly describe any and all self-care practices you have here:
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Please briefly describe any spiritual or religious practices you may have here:
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How would you describe your relationship with money?
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Have you taken or attended any personal growth courses, seminars, workshop, etc? Please explain.
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What are the last 3 books you've read?
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Will family and/or friends be supportive of your desire to make changes to achieve your desires and goals?
*
What specifically excites you about having a coach?
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What hesitations, if any, do you have about working with a coach?
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The most important thing I should do to improve my life is...
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What is your main goal/focus right now?
Any additional concerns or goals list here:
If there is anything else you would like to share or feel would be helpful for me to know, please share below.
