Wellness Coaching Initial Consult
Get to know the client before our first meeting to enhance knowledge of lifestyle behaviors and background
What is your first and last name?
What is your phone number and E-mail address?
What is your age, current height and weight?
What are your major health and nutrition goals?
How would you describe your present state of health?
When was the last time you visited your physician?
Please check any that apply to your health
High blood pressure
Irritable bowel syndrome
Have you had any major surgeries?
Have you had any past injuries?
Describe any other health conditions
Has anyone in your immediate family been diagnosed with the following? If so please add whom and relation to you.
High blood pressure or cholestrol
Have you had any recent weight changes? If yes please explain.
Have you used any weight loss programs or diets?
What do you consider to be the major issues in your diet and eating plan?
How many glasses of water do you drink per day?
8 or more
How often do you dine out?
How often do you prepare meals at home and who prepares them?
Do you drink caffeine?
If yes how much?
Do you drink alcohol?
If yes, how much per day? per week? per month?
Do you smoke?
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