Initial Consultation Form

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The information you provide will serve as the foundation for your program and the more complete the information the more likely you are to reach your goals. For required fields that don't apply please enter 'None' or 'NA'.

Please allow 60 minutes or more to complete the form. At the bottom the form there is an option to 'Save and Return Later' for your convenience.

We request that you complete the form at least 2 full business days in advance of your appointment so we have time to prepare for your coaching session.
Name*
First Last
Email*
Main Health Goals
Please describe the health and lifestyle transformation you desire to achieve during this Health Coaching relationship.*
Describe the patterns you seem to fall into again and again with regard to making health and lifestyle transformation. What other diets, programs, or approaches have you tried in the past, and what were your results?*
Describe your beliefs about your ability to transform your own health.*
What support do you have at home, at work, and in your life to succeed in this program?*
What barriers can you perceive or predict? What aspects of your home, work, and life have previously detracted from your ability to succeed?*
What hobbies, interests, and passions do you partake in?*
Please share any information you feel is pertinent with regard to your level of commitment through this process. What is going to motivate you to keep going even when it gets a little uncomfortable?*

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Nutrition
Diet snapshot. Generally, how would you describe your current diet? Provide a basic snapshot of what an average day looks like: Breakfast, lunch, dinner, snacks, treat and beverages. Please include times of day as well.*
Protein. Which protein sources do you eat? How often do you eat them?*
Whole grains. What types of whole grains do you eat? How often do you consume them?*
Refined carbohydrates. What types of refined carbohydrate snacks (like candies, crackers, cookies, pastries, baked goods) do you eat? How often do you eat them?*
What are your favorite foods?*
Do you try to avoid any certain types of foods?*
What foods do you crave? How often do you give in to the cravings?*
Do you experience any symptoms/feelings/behaviors if meals are missed? Explain.*
Are you currently taking any nutritional supplements? List all.*

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Beverages
How many glasses or servings of the following do you have in a day or week? Please provide quantity and frequency.
Water Servings
Per
Coffee Servings
Per
How do you take your coffee?
Tea Servings
Per
How do you take your tea?
Fruit or vegetable juice; kombucha Servings
Per
Please provide details around your consumption of juices: type, when, why?
Milk Servings
Per
Milk (non-dairy) Servings
Per
Please provide details around your dairy and non-dairy milk usage: type, when, why?
Smoothies or shakes Servings
Per
Please provide details: smoothie/shake ingredients; when and why you consume smoothies or shakes, etc.
Soda
Per
Diet Soda
Per
Alcoholic beverages
Per
Please provide details: What type of alcoholic drink, when, why?

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Work & Life
What do you do for work?*
Do you usually enjoy your work?*
- Yes
- No
How many hours a day do you work?*
Please enter a number from 0 to 24.
What type of schedule do you work? Check all that apply:*
- Regular Schedule
- Random Schedule
- Shift Work
If you answered 'random schedule,' briefly explain what that means.
What is your family and home-life situation? Married? Children? Taking care of elderly parents? Please describe with as much detail as you feel comfortable sharing.*

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Energy & Mood
Describe your energy levels throughout the day. Do you have highs and lows? When?*
On a scale of 1 to 10, how would you rate your stress level?*
Please enter a number from 1 to 10.
Describe your sources of stress.*
How do you react to stress? Do you rely on any coping mechanisms?*

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Conclusion
Do you have any additional notes, comments or questions?
Acknowledgement*
Client Acknowledgement
I understand that the services provided are at all times restricted to consultation on the subject of health matters intended for general well being and are not meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of medicine. This statement is being acknowledged voluntarily.
Phone
This field is for validation purposes and should be left unchanged.