Whole Body Balance Strategy Session Form
Take a few minutes to let me know where you are and where you want to be.

I will be in touch with you to set up a time to talk (if we haven't already set up a time) and create a plan for you. Thank you for caring about your health!


Email address *
Full Name: *
Your answer
Cell phone: *
Your answer
Health Information:
List your main health goals: *
Your answer
What physical, mental, and emotional issues do you want to resolve? *
Your answer
What were your health challenges as a child or younger adult? *
Your answer
Would you like your weight to be different? If so, heavier or lighter? *
Your answer
Do you use pharmaceuticals? If so, which? *
Your answer
Social Information
Occupation: *
Your answer
Hours of work (however you define it) per week: *
Are you overwhelmed or frequently stressed out? *
Do you sleep well? *
How many hours? *
How much do you exercise? *
Your answer
Do you exercise enough? *
Your answer
Do you meditate? *
Do you drink caffeine or alcohol? If so, do you drink either too much for your body at this phase in your life? *
Your answer
Do you prepare your own food? *
How committed are you to making changes in your diet and lifestyle if you know the changes would accelerate your wellness? *
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? *
Thank you for caring about your well-being. I'll get right back to you.
I'm leaving you some space if there's anything else you'd like to share with me. Hopes, hesitations, funny jokes appreciated.
Your answer
A copy of your responses will be emailed to the address you provided.
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