All of your information will remain confidential between you and your coach.
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
Would you like your weight to be different? If so, what?
Relationship status
Children
Occupation
Hours of work per week
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?
Do you take any supplements or medications? Please list
Any healers, helpers or therapies with which you are involved? Please list
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:
Anything else you would like to share?
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