A Journey to Wellness Initial Consultation
Full Name
*
First Name
Last Name
Gender
Male
Female
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
years
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Preferred Contact Method
Briefly describe what "healthy" looks like to you.
NUTRITION
Do you eat Breakfast? Briefly describe a typical breakfast.
Do you follow a specific eating style or diet?
Yes
No
Do you consume vegetables/greens on a daily basis?
Never
Rarely
Occasionally
Always
On average, how many sugary drinks do you consume in a day? (Juice, sweet tea, sodas, etc.)
How many caffeinated beverages do you consume a day?
How many teaspoons of sugar do you have in your tea or coffee?
What do you snack on during the day?
How often do you make eating decisions you regret?
Never
Rarely
Sometimes
Often
Very often
Do you often overeat or eat when bored, emotional?
Do you have uncontrollable cravings for sugary or processed foods ("junk food")?
Around what time in the evening do you stop eating?
What time of day do you feel the hungriest or eat the most?
What do you typically eat for lunch?
What do you typically eat for dinner?
Do you take any supplements/vitamins?
Yes
No
If so, please state which ones
On average, how much water do you drink a day?
Please list your dietary preferences and goals. (Foods you love, foods you do not eat, foods you would like to start eating more of)
SLEEP
On average, how many hours of sleep do you get a night?
Do you have any diagnosed health issues? ( I do not treat health conditions but I can use this information to gain more of an understanding of your needs)
What time do you usually go to sleep?
How would you rate your sleep quality?
Very poor
Poor
Average
Good
Very Good
How would you rate your energy levels when you wake up in the mornings?
Very poor
Poor
Average
Good
Very good
How would you rate your energy levels throughout the day?
Very poor
Poor
Average
Good
Very good
Stress
On a scale of 1-10 what would you rate your general level of anxiety/stress?
Do you currently use any techniques or methods to cope with stress?
Yes
No
If so, please describe the methods below.
Do you suffer from chronic pain, skin problems, or digestive issues?
Do you pray or meditate to help cope with stress?
If there are any, please list any negative or unhealthy habit you would like to change.
Please list any habits or lifestyle changes you would like to begin.
Exercise/ Fitness
How many times a week do you exercise/move with some intensity?
Which kind(s) of exercise/movement do you do and for how long?
Are you willing to follow an exercise routine?
Do you own any exercise equipment or do you have a gym membership?
If you have any injuries that may interfere with exercise, please list them.
How much time would you be willing to give yourself for a morning routine?
How much time would you be willing to give yourself for an evening routine?
List up to three short-term goals you would like to start working towards.
What are some ways you can stay accountable? What could you do to reward yourself for sticking with your new routine?
Please rate your readiness for change. How serious are you about making and maintaining a lifestyle change?
1
2
3
4
5
6
7
8
9
10
Schedule an over-the-phone appointment (optional)
Submit
Should be Empty: