Your Name (required) Your Email (required) Phone Age Height Birth date Weight What is your current weight? What is your ideal weight? Relationship status —Please choose an option—MarriedSingleLive-in PartnerIn a RelationshipGoing Through a DivorceOther Children Names, ages, do they live with you? Animals Do you have any pets? Describe the role they play in your life. Occupation What do you do and how many hours per week do you work? If you aren't working or are in transition, please explain. Lifestyle Is your lifestyle sedentary or active? Explain for both work and home. Media consumption Describe your computer/tablet/phone and television viewing habits. Stress Rank your level of stress on a scale of 1-10. What are the biggest stressors in your life? How does stress affect you? Spirituality How and when do you feel connected to something greater than yourself? Mental Health Please describe your emotional, physiological and social well-being on a day to day basis. Please include any mental struggles you face and any needs you feel aren't being met. Sleep Please describe your sleeping habits. Life Concerns Why are you seeking coaching right now? Where and how would you like to focus? Disorders Do you have any serious illnesses, chronic disorders or injuries? Happiness How happy are you? Explain. Medication Please list the medications and supplements that you take. Therapy Are you involved with any healers, therapists, support programs or other advisors? Please explain. Exercise How often do you exercise? Is your current routine (or lack thereof) enough to sustain your desired level of fitness? Women's Health Do you experience any cyclical symptoms? Current Diet On a scale of 1-10, please rate your diet, with 10 being "couldn't possibly be healthier." How could your diet improve? Food priorities Do you prioritize quantity, quality, taste, convenience, ingredients, food source and/or certain diet preferences? Do you manage calories, carbs, fat and/or protein ratios? Cravings Do you crave sugar, coffee, cigarettes, alcohol or fast food? What and when? Addictions Are you addicted to any substances (illegal, legal, prescription or otherwise)? How does addiction impact your life? Support What is your support system like? Consider spouse, family, friends, co-workers, etc. Where do you have support and where is it lacking? #1 What is the most important thing you know you should do to improve your health? Motivates What motivates you? What do you procrastinate/avoid? Personality Do you prefer professionals who tell you what to do? Or do you prefer lots of information and options so you can do your own research? Please comment on your personality style and preferences to health recommendations. Anything else? Is there anything else you'd like to share? Δ
