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?