Health Coach Consultation Form
Congratulations on taking the first step in upgrading your health to the vibrant life you deserve! Working with a Health Coach is a transformative experience like no other and I'm excited you found your way here.

If you think you might like to work with me to feel more powerful and in control of your health…I like you already. My clients lose weight, have more energy, bust sugar cravings – and most of all, find the strength to take great strides in improving their self-confidence, personal life and overall capacity to navigate the world without being constrained by the chains of a one-size-fits-all diet.

Please complete this form prior to your health consultation appointment. Clients are accepted by application only, so this is the first step helping me learn more about you and YOUR needs.

Upon completion of the questionnaire I will be in touch to confirm your consultation session. Any questions? Contact me at beth@myhealthytransitions.com. I look forward to hearing from you! ~ Beth

Email address *
Name (First, Last) *
Your answer
Address (Street, City, Zip) *
Your answer
Phone (primary) *
Your answer
Age *
Your answer
Birthdate *
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Height *
Your answer
Current weight *
Your answer
Body fat percentage
Your answer
Weight 6 months ago *
Your answer
Weight one year ago *
Your answer
Would you like your weight/body composition to be different? If so, what would that weight be? *
Your answer
How would you describe your self esteem and confidence in various areas of your life? *
Your answer
Relationship status *
Do you have children? If so, how many? *
Your answer
Describe how you feel about your personal relationships with family and friends? *
Your answer
Occupation: *
Your answer
Hours of work per week: *
Your answer
How do you feel about your career & purpose? *
Your answer
Please list your main health concerns: *
Your answer
Other concerns, questions and/or overall health goals? *
Your answer
At what point did you feel your best? *
Your answer
Any serious illnesses or hospitalizations?
Your answer
Autoimmune or other diagnosed health conditions? *
Your answer
Any pain/stiffness/swelling? *
Your answer
How is your digestion? Frequency of eliminations? Constipation, diarrhea, gas, bloating, reflux? *
Your answer
Allergies or other sensitivities? (food or other) *
Your answer
Have you had your thyroid tested? If so, what tests (TSH, T3, T4, free T3, free T4, reverse T3) and when? *
Your answer
Any other functional lab testing? *
Your answer
(Women's Health) Describe your menstrual cycle: *
Your answer
Do you take any supplements or medications? If so, please list. *
Your answer
Any healers, helpers or therapies in which you are involved? *
Your answer
What role does exercise play in your life? *
Your answer
How would you describe your stress levels? *
Your answer
How is your sleep? How many hours? Do you wake up at night? *
Your answer
Describe your typical diet (what you eat breakfast, lunch, snacks, dinner, dessert) *
Your answer
How often do you eat? *
Your answer
Are you currently following a particular dietary protocol (e.g. Paleo, vegan, keto, low FODMAP, AIP, IIFYM)? If so, how do you feel like this approach is currently working for you?
Your answer
Do you cook? What percentage of your meals are home cooked? Where do you get the rest from? *
Your answer
Are there any foods you do not like to eat, and/or foods you cannot eat due to food allergies or sensitivities? *
Your answer
Have you tried any diets in the past? If so, what was your experience? *
Your answer
Do you have sugar cravings? *
How do you feel about your current nutrition and eating behaviors? *
Your answer
Do you have any other addictions or unhealthy habits (cigarettes, caffeine, etc.)? *
Your answer
What type of support system do you have for your health & wellness goals? *
Your answer
The most important thing I could do to improve my health is: *
Your answer
In what areas do you feel you need the most support? *
Your answer
If you were to engage in a custom health coaching program, what would success look like to you? *
Your answer
On a scale of 1-10, how ready are you to make an investment and commitment to your health goals? *
A copy of your responses will be emailed to the address you provided.
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