All of your information will remain confidential between you and your coach.

    Personal Information

    First Name*

    Last Name*

    Email*

    Home Phone

    Mobile Phone

    Age

    Height

    Birthdate

    Place of Birth

    Where do you live now?

    Current Weight

    Weight six months ago

    Weight one year ago

    Current Weight

    Would you like your weight to be different? If so, what?

    Social Information

    Relationship status

    Children

    Occupation

    Hours of work per week

    Health Information

    Please list your main health concerns

    Other concerns and/or goals?

    Any serious illnesses/hospitalizations/injuries?

    How is/was the health of your mother?

    How is/was the health of your father?

    How is your sleep?

    How many hours do you sleep?

    Do you wake up at night?

    Why?

    Any pain, stiffness or swelling?

    Constipation/Diarrhea/Gas?

    Allergies or sensitivities? Please explain

    Are your periods regular?

    Painful or symptomatic? Please explain

    Reached or approaching menopause? Please explain

    What role do sports and exercise play in your life?

    Medical Information

    Do you take any supplements or medications? Please list

    Any healers, helpers or therapies with which you are involved? Please list

    Food Information

    What foods did you eat often as a child?

    Breakfast

    Lunch

    Dinner

    Snacks

    Liquids

    Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

    Do you cook?

    What percentage of your food is home-cooked?

    Where do you get the rest?

    Do you crave sugar, coffee, cigarettes, or have any major addictions?

    The most important thing I should do to improve my health is:

    What is your food like these days?

    Breakfast

    Lunch

    Dinner

    Snacks

    Liquids

    Additional Comments

    Anything else you would like to share?