Initial Consultation Form

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Date

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.*

If you had a magic wand and could erase three problems, what would they be?

Problem 1*

DIscomfort Rating*

Mild

Moderate

Severe

Problem 1 - Treatments/Therapies*

Success Rating*

Excellent

Good

Fair

Poor

Problem 2

DIscomfort Rating

Mild

Moderate

Severe

Problem 2 - Treatments/Therapies

Success Rating

Excellent

Good

Fair

Poor

Problem 3

DIscomfort Rating

Mild

Moderate

Severe

Problem 3 - Treatments/Therapies

Success Rating

Excellent

Good

Fair

Poor

When was the last time you felt well?*

Did something trigger your change in health?*

What makes you feel worse?*

What makes you feel better?*

Describe the patterns you seem to fall into again and again with regard to making health and lifestyle transformation.*

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?*

Medical History

Current health conditions. Have you been diagnosed with any diseases, and/or are you on any prescribed medications?*

Please provide diagnosis, date of diagnosis and corresponding medication(s).

Have you ever been hospitalized, had any major surgery?*

Please provide date and reason.

Do you have any implants? If so, please describe.*

Implants include artificial joints (such as hip and knee joints), breast implants, pacemakers, contraceptive implants, stents, other cosmetic implants, mesh for hernia repair etc.

Do you have any allergies or sensitivities to medications, food or supplements?*

Yes

If yes, please describe:*

Do you smoke?*

Yes

If yes, please describe:*

Do you partake in recreational drugs?*

Yes

If yes, which ones, how often, and why?*

Describe any pertinent family medical history.*

Are you a female?*

Yes

Are you or could you be pregnant?*

Yes

Are you pre-menopausal, peri-menopausal, menopausal, post menopausal or experiencing menopausal symptoms? Please describe.*

Pre - normal cycle. Peri - decline in estrogen causing irregular periods, hot flashes, and mood swings. Meno - 12 months without a period. Post - More than 12 months.

Dental History

Do you have or have you ever had any amalgam (silver) fillings?*

Yes

If yes, how many?*

Do you have any root canals?*

Yes

If yes, how many?*

Do you have any crowns?*

Yes

If yes, how many and type if known?*

Porcelain, gold, bio-compatible materials or other.

Have you had any teeth removed?*

Yes

If yes, how many?*

Do you have any dental implants?*

Yes

If yes, how many and type if known?*

Titanium, bio-compatible materials (such as zirconia) or other.

Do you have any known oral health issues?*

Yes

If yes, please describe:*

Bowel Health

How often do you have a bowel movement?*

Do you ever have difficult or unusual bowel movements? If so, describe.*

Work & Life

What do you do for work?*

Do you usually enjoy your work?*

Yes

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.*

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?*

Sleep

Sleep quality. Check all that apply:*

I fall asleep easily.

I stay asleep well.

I wake up feeling rested.

I snore.

I have sleep apnea.

I have trouble falling asleep.

My mind wanders which keeps me awake.

I wake up in the night but can get back to sleep usually.

I wake in the night and then can't get back to sleep.

I struggle to wake up when my alarm goes off.

I feel unrested when I wake up.

Sleep quantity. How many hours of sleep do you get most nights?*

Please enter a number from 1 to 10.

What time do you typically go to bed?*

Hours

Minutes

AM/PM

What time do you typically wake up?*

Hours

Minutes

AM/PM

What else should your coach know about your sleep habits, patterns, quantity, and quality?*

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.*

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?

Exercise & Movement

Non-exercise movement. Non-exercise movement can include things like the walking you do throughout your day, moving around, chores, manual/physical tasks, fidgeting, etc. Please describe your daily nonexercise movement.*

Exercise. Exercise is described as the deliberate attempts you make to move your body; your workouts, weight lifting sessions, yoga or fitness classes, and taking long walks. What do you do for exercise? Describe the types of activities, frequency, duration, intensity, etc.*

Are you a competitive athlete?*

Yes

If so, describe your sport(s):*

What are your fitness goals? Check all that apply:*

General health

Muscle mass gain

Fat loss

“Looking Good Naked"

Improved physical performance

Improved bone density

Improved cardiorespiratory health

Preventing age-related muscle loss

Stress management

Improved mood

Other

Describe your performance goals:

If you chose Other, please describe your fitness goals:

Do you have any physical limitations in terms of your ability to partake in an exercise program?*

Conclusion

Do you have any additional notes, comments or questions?

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.

Client Acknowledgement

This field is for validation purposes and should be left unchanged.