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(866) 570-1827
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Process
Coach Ken
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Client Portals
Primal Blueprint
Primal Kitchen
Systemic Formulas
Virtual Clinic
Programs
Primal Living
Complete Body Reset
Advanced Wellness
Emotional Wellness
Custom Health Coaching
Process
Coach Ken
FAQs
Resources
Health & Wellness
Air Purifiers
Contact
Client Portals
Primal Blueprint
Primal Kitchen
Systemic Formulas
Virtual Clinic
Facebook
Linkedin
Coach@RabbitHoleHealthCoaching.com
(866) 570-1827
Free Discovery Call
free discovery call
Programs
Primal Living
Complete Body Reset
Advanced Wellness
Emotional Wellness
Custom Health Coaching
Process
Coach Ken
FAQs
Resources
Health & Wellness
Air Purifiers
Contact
Client Portals
Primal Blueprint
Primal Kitchen
Systemic Formulas
Virtual Clinic
Programs
Primal Living
Complete Body Reset
Advanced Wellness
Emotional Wellness
Custom Health Coaching
Process
Coach Ken
FAQs
Resources
Health & Wellness
Air Purifiers
Contact
Client Portals
Primal Blueprint
Primal Kitchen
Systemic Formulas
Virtual Clinic
initial consultation form
Step
1
of
11
9%
Hidden
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.
*
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?
*
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
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
Coffee Servings
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
How do you take your coffee?
Tea Servings
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
How do you take your tea?
Fruit or vegetable juice; kombucha Servings
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
Please provide details around your consumption of juices: type, when, why?
Milk Servings
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
Milk (non-dairy) Servings
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
Please provide details around your dairy and non-dairy milk usage: type, when, why?
Smoothies or shakes Servings
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
Please provide details: smoothie/shake ingredients; when and why you consume smoothies or shakes, etc.
Soda
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
Diet Soda
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
Alcoholic beverages
0
1
2
3
4
5
6
7
8
9
10
Per
Day
Week
Please provide details: What type of alcoholic drink, when, why?
Medical History
Current health conditions. Have you been diagnosed with any diseases, and/or are you on any prescribed medications?
*
Have you ever been hospitalized, had any major surgery? Please describe.
*
Do you have any allergies or sensitivities?
*
Yes
No
If yes, please describe:
*
Do you smoke?
*
Yes
No
If yes, please describe:
*
Do you partake in recreational drugs?
*
Yes
No
If yes, which ones, how often, and why?
*
Describe any pertinent family medical history.
*
Are you a female?
*
Yes
No
Are you or could you be pregnant?
*
Yes
No
Are you pre-menopausal, peri-menopausal, menopausal or experiencing menopause symptoms? Please describe.
*
Dental History
Do you have or have you ever had any amalgam (silver) fillings?
*
Yes
No
If yes, how many?
*
Do you have any root canals?
*
Yes
No
If yes, how many?
*
Do you have any crowns?
*
Yes
No
If yes, how many and type if known?
*
Porcelain, gold, bio-compatible materials or other.
Have you had any teeth removed?
*
Yes
No
If yes, how many?
*
Do you have any known oral health issues?
*
Yes
No
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
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.
*
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:
*
Select All
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
AM/PM
What time do you typically wake up?
*
:
Hours
Minutes
AM
PM
AM/PM
What else should your coach know about your sleep habits, patterns, quantity, and quality?
*
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
No
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
*
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.
Name
This field is for validation purposes and should be left unchanged.
Δ
Questions?
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contact coach ken
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