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Discovery Session Wellness Consult
Initial Health Coaching Consultation
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Email
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PERSONAL INFORMATION
Name
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Your answer
Best Email
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How often do you check email?
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Best way to communicate with you
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Cell Phone
Text Message
Email
Other:
Age
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Birthdate
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DD
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YYYY
Height
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Current Weight
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Weight Six Months Ago
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Weight One Year Ago
Your answer
Would you like your weight to be different?
Yes
No
Maybe
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Is so, what?
Your answer
SOCIAL INFORMATION
Relationship Status
Your answer
Children
Your answer
Pets
Your answer
What do you like to do for fun?
Your answer
Occupation
Your answer
Hours of work per week
Your answer
HEALTH INFORMATION
Please list your main health concerns
Your answer
Other concerns and / or goals
Your answer
At what point in your life did you feel your best?
Your answer
Any serious illness, hospitalizations or injuries?
Your answer
How was the health of your mother?
Your answer
How was the health of your father?
Your answer
What is your ancestry?
Your answer
What is your blood type?
Your answer
Do you sleep well?
Your answer
How many hours a night?
Your answer
How many hours at a time?
Your answer
Do you wake up at night? If so, why?
Your answer
Do you have any stiffness or swelling?
Your answer
Do you have any constipation, gas, bloating or diarrhea?
Your answer
Do you have any allergies or sensitivities? If so, please explain.
Your answer
WOMEN ONLY: Menstruation Status
Regular Periods
Irregular Periods
Menopause
Not applicable
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WOMEN ONLY
Birth control history
Your answer
Do you experience yeast infections or frequent urinary tract infections? If so, please explain.
Your answer
MEDICAL INFORMATION
List any medications or supplements you take.
Your answer
Do you use any alternative therapies? (Acupuncture, chiropractics, massage, reiki, etc)
Your answer
What role does exercise or sports play in your life?
Your answer
FOOD INFORMATION
WHAT FOODS DID YOU EAT AS A CHILD?
Breakfast: What did you typically eat for breakfast as a child?
Your answer
Lunch: What did you typically eat for lunch as a child?
Your answer
Dinner: What did you typically eat for dinner as a child?
Your answer
Snacks: What did you typically eat for snacks as a child?
Your answer
Liquids: What did you typically drink as a child?
Your answer
CURRENT MEALS
Breakfast: List the breakfast choices you consume throughout the week.
Your answer
Lunch: List the lunch choices you consume throughout the week.
Your answer
Snacks: List the snack choices you consume throughout the week.
Your answer
Liquids: List the beverage choices you consume throughout the week.
Your answer
Do you cook?
Your answer
What percentage of your food is cooked at home?
Your answer
Where do you get the rest of your food from?
Your answer
Do you crave sugar, coffee, cigarettes or any other addictions?
Your answer
Will your family or friends be supportive of your desire to make food and/or lifestyle changes?
Your answer
What is the most important thing you can do to change your diet and improve your health?
Your answer
On a scale from 1 - 10, 10 being the most committed and 1 being the least committed, How committed are you to make the necessary changes to live a healthier lifestyle?
Not committed
1
2
3
4
5
6
7
8
9
10
Extremely committed - Let's do this!
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ADDITIONAL COMMENTS
Is there anything else you would like to share?
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