First Name
Last Name
Email
Home/Mailing Address
Phone Number (Primary)
Phone Number (Alternative)
Date of Brith
Place of Birth
Age
Height
Current Weight
Weight 6 mo ago (if weight consult)
Weight 1 yr ago (if weight consult)
Would you like your weight to be different? (If yes, how so)?
Relationship Status
Do you live with others? (If so, who?)
Do you have pets?
Do you have children?
Occupation?
How many hours per week do you typically work?
How many hours do you spent stagnant (sitting/standing, non-mobile) during each work day?
How content/satisfied are you with your current occupation/employment?
What are you main health concerns?
Do you have any other concerns or goals (related to health or otherwise)?
At what point in your life did you feel your best? (And why do you think that might be)?
Do you have any current or previous serious illnesses, hospitalizations, surgeries (including dental work), or injuries?
Were you raised by your biological parent(s)?
What is your ancestry/heritage (if known)?
What is your blood type (if known)?
How is /was your mother's health?
How is/was your father's health?
How is your partner/spouse's health (if applicable)?
How is your child/children's health (if applicable)?
How is/are your pet(s)' health (if applicable)?
Are there any other family health factors you feel are important to share?
How is your sleep?
How many hrs do you typically sleep/night?
How satisfied are you with your sleep?
Do you wake up during the night? If so, why?
What time do you usually (a) go to bed & (b) fall asleep?
What time do you usually (a) wake up & (b) get out of bed?
Do you use an alarm for sleeping or waking?
Do you have any pain, stiffness, or swelling (acutely/presently or chronically/ongoing)?
Do you have any constipation, diarrhea, gas/flatulence, bloating, indigestion, or other gastrointestinal issues?
Do you have any allergies or sensitivities?
Please list all vitamins, supplements, herbs, pre/probiotics and other over-the-counter medications you currently take
Please list all prescription medications you currently take
Please list any/all medications (prescription and/or over-the-counter), vitamins, supplements, herb, and/or pre/probiotics you have previously taken but no longer take (that you feel are relevent to this coaching experience)
Do you currently take or have you previously taken antibiotics?
Are you currently involved with any healers, helpers, or therapies?
Do you engage in any independent practices for health, wellness, or healing?
What role do sports and exercise plan in your life?
Have you ever had a very negative experience involving sports, exercise, or movement that stands out to you as shaping your views and current experiences with sports, exercise, and/or movement?
How connected do you feel to your body?
Will your family and friends be supportive of your desire to make food and/or lifestyle changes?
Please identify three (3) individuals in your life who are or can be supportive of your desire to make food, lifestyle, or behavioral changes?
Do you cook?
What percentage of your food is home-cooked?
Where does your non-home-cooked food come from?
What foods and liquids did you often have for breakfast as a child?
What foods and liquids did you often have between breakfast and lunch as a child?
What foods and liquids did you often have for breakfast as a child?
Do you typically eat breakfast? If so, when and where do you typically eat this meal (e.g,. sitting at kitchen table, at home while getting ready, in car, at office, at desk, at coffee shop, cafeteria with others or solo), what foods and/or liquids do you typically consume, are these foods/liquids typically prepared by you (e.g., at home) or others (e.g., purchased/grab-and-go), do you typically eat this meal alone or with others, and how long do you typically have or take to consume this meal?
Do you consume any snacks or liquids between breakfast and lunch?
Do you typically eat lunch? If so, when and where do you typically eat this meal (e.g,. home, at office, at desk, at coffee shop, cafeteria with others or solo), what foods and/or liquids do you typically consume, are these foods/liquids typically prepared by you (e.g., at home) or others (e.g., purchased/grab-and-go), do you typically eat this meal alone or with others, and how long do you typically have or take to consume this meal?
Do you consume any snacks or liquids between lunch and dinner?
Do you typically eat dinner? If so, when and where do you typically eat this meal (e.g,. home, at office, at desk, at coffee shop, cafeteria with others or solo), what foods and/or liquids do you typically consume, are these foods/liquids typically prepared by you (e.g., at home) or others (e.g., purchased/grab-and-go), do you typically eat this meal alone or with others, and how long do you typically have or take to consume this meal?
Do you consume any snacks, meals, or liquids between dinner and bedtime?
Please list all forms of caffeine you typically consume in a day (and respective amounts). These include: decaf and regular coffee, tea, foods or beverages containing chocolate, cacao, energy drinks, supplements or smoothie mixes containing caffeine (e.g., caffeine anhydrous, coffee bean, green tea, white tea, matcha, etc.), or Excedrin, or caffeine tablets.
Do you consume alcohol? If so, how much and how frequently? (e.g., 1 glass of wine ~3 nights/wk; 3 beers on Fri, Sat, and Sun; two hard alcohol beverages nightly, etc.
Do you use any recreational or ceremonial drugs? If so, please describe type, amount, and frequency?
Do you engage in any behaviors in which you feel like you loose control or do not have a choice?
If you engage in any behaviors in which you feel you lose control or do not have the power of choice, how frequently do you engage in these behaviors and how long has this occurred for?
Do you experience any cravings (e.g., for sugar, coffee, cigarettes, gambling, video gaming), etc? If so, how frequently do you engage in these behaviors?
Are there any dietary changes you feel you need to prioritize NOW to improve your health or life?
Are there any dietary changes you feel you need to prioritize NOW to improve your health or life?
Are there any movement or exercise changes you feel you need to prioritize NOW to improve your health or life?
Are there any relationship changes you feel you need to prioritize NOW to improve your health or life?
Are there any social changes you feel you need to prioritize NOW to improve your health or life?
Are there any work changes you feel you need to prioritize NOW to improve your health or life?
Are there any behavioral changes you feel you need to prioritize NOW to improve your health or life?
Are there any emotional changes you feel you need to prioritize NOW to improve your health or life?
Are there any mental health/wellness changes you feel you need to prioritize NOW to improve your health or life?
Are there any financial changes you feel you need to prioritize NOW to improve your health or life?
Are there any other changes you feel you need to prioritize NOW to improve your health or life?
Is there anything else you would like to share?
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