We Glow Initial Enrolment Form

WE GLOW
Holistic Health Analysis

We Glow Wellness
Tell me a bit about you.

Please take some time to complete this form. By learning more about you, I will be able to better support you along your journey to your highest self. 🌸
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age
years
Email*
example@example.com
Phone Number*

Area codePhone Number
Height
cm
Weight
KG
What is your overall goal?*
Please describe any past or current products, programs, plans, methods or support you have tried.*
Which of those worked well and did not work well?*
Tell me why.
Health
Previous blood tests:

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Additional health information:

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If you have any diagnosed health problems list the condition(s).*
Do you experience or have you previously experienced any chronic illnesses or disease?*
If family members have experienced similar conditions, please describe. *
If you are on any medications, please list them.
If you are taking any herbs, vitamins, minerals or nutritional supplements, please list them.*
Please list any recent prescription medications.
Have you had any vaccinations?*
Please describe what ones if you are able to.
Did you take antibiotics frequently as a child?*

YesNoNot sure
Dental
Do you have any fillings or root canals?*

YesNo
Did you used to wear braces?*

YesNo
Do your gums bleed when brushing?*

YesNo
Do you have any mercury fillings or root canals?

YesNo
Do you grind your teeth during your sleep?
When sleeping, do you breathe through your nose or mouth?
Is there any other dental matters you'd like to tell me about?
Mindset
Do you have any routine within your days/ week?
Tell me briefly more.
How would you rate your overall happiness?*
How would you rate your overall body image and relationship with yourself?*
Do you feel you have any limiting beliefs?
Have you experienced any significant trauma during your life?
If comfortable to do so, please tell me more
Do you experience any signs anxiety or depression?
Please describe any self-care practices you currently do.*
Meditation, deep breathing, massage, grounding, yoga, mindfulness, reading, journaling etc.
Is there anything more you'd like to tell me in regards to mindset and mental wellness?
Women's Health
Are you aware and in-tune with your menstrual cycle?

YesNoI don't knowOther
Please tell me a little about your period and/or menstrual health.*
Period flow, symptoms, regularity etc
What is your average cycle length?
Do you track your cycle?

YesNo
If you do track your cycle, what method do you use?
How old were you when you got your first period?*
If relevant.
Have you had children?*

YesNo
Have you previously experienced any fertility complications?*
Are you taking the oral contraceptive pill or have you previously? *
If so, for how long or how long ago did you stop?
Are you using any other period regulatory methods or have you previously? (eg. copper IUD, mirena)*
In terms of contraception, what method do you follow?
If applicable.
Is there anything else you'd like to share in regards to women's health?
Symptom Guide
Please check if you experience any of the following.*

Pain in lower backExcessive thirstFeel stiff after sitting for too longBrain fogHeadachesAnxiousnessDepressive feelings or sadnessFatigueExcessive urinationMetallic taste in mouthBody achesLow self-confidence/ self-esteemDry/ thinning hairDry skinAcneOily skinHighly emotionalStore fat easilyEasily bruisedHungry upon wakingShaky if missed a mealFungal infections (athletes foot, yeast infection, skin fungus)Bad breathPoor sleep qualityDehydratedGrind teethDecreased libidoMucous film on tongueBloatingCravingsItchy skinIndecisivenessOther
Please list and explain any other symptoms you have noticed.*
Please rate your current stress levels.*
Please rate your perceived ability to manage and prevent stress.*
How do you normally cope with stress?*
What are the main stressors in your life at the moment?
Have you always been a "stressed" person?
If applicable.
Please tell me a bit about your sleep.*
Bed time, sleep duration, time to fall to sleep, waking during night, wake time, wakefulness/ energy, need to sleep/nap during the day.
Do you have a sleep routine? (if so, please tell me more)
What do you do before you go to sleep?
Digestion
Do you experience or have you previously been diagnosed with any digestive concerns?
IBS, SIBO, Leaky Gut, etc
Please rate your digestion.*
Bowel movement frequency.*

1 per day1-3 times per daynot everydayevery few daysOther
Please indicate what type your stool generally is.*
See below Bristol Stool Chart.
Please let me know if you experience any other digestive concerns.
Bloating, gas, pains, cramping etc.
Movement
What do you do for a living?*
What is you average daily step count?*
Do you partake in any other forms of physical activity on a frequent basis? *
Please describe .
Do you engage in strength training?
How often do you train?
Have you currently got any injuries?*
Please list any past injuries or operations.*
Include broken bones and soft tissue injuries.
How often do you spend time walking in nature?*
How many minutes per day (approximately) would you spend in the sunshine?
What is your most enjoyed style of training/ movement?
Strength, yoga, pilates, HIIT, running, walking, boxing, etc
Nutrition
Have you or do you currently follow a diet or nutrition plan/ lifestyle diet? (If yes, please describe and state duration).*
For example vegan, vegetarian, gluten free, 'low carb', keto-genic, Paleo, low-FODMAP etc.
Do you find food "stressful" or experience feelings of anxiety?
Please explain how you feel and when these feeling arise.
Do you eat the same types/ quantities of food during the week as you do on the weekend?
Have you had any troubles with binge eating in the past/ currently?
How would you rate your overall relationship with food?*
How would you rate your overall diet and nutrition habits?*
How much water do you consume daily?*
Do you drink alcohol or smoke?*
If so, how often?
Are you allergic or intolerant to any foods or do you avoid any foods/ ingredients?*
For example: dairy, gluten, nuts etc
Do you experience any cravings? *
Please list them.
Do you count/track your caloric intake?*

YesNoNot currently (I have in the past)Other
Do you know approximately how many calories you consume daily? (If yes, please state amount).*
What is the duration you have consumed the above calories?*

Please list the foods you currently eat on an average usual day. (Leave section blank if you do not consume a meal at that time).*

	List all food ingredients	Quantity	Drinks	Supplements
Morning
Mid-morning
Mid-day
Mid-afternoon
Evening
Late evening

What time of the day do you consume each meal?*
Please list any other regularly consumed food not listed above.

How do you feel after you consume a main meal?*

	1	2	3	4	5

1 is Worst, 5 is Best

Please describe anything you experience after consuming a main meal.*
Fatigue, anxiousness, bloating, need to go to toilet etc
Please list any foods you absolutely love!
List below any supps, or vitamins you are taking (or medication if you have not already done so).
Relationships
Are you currently in a relationship?*
How would you rate your overall happiness with yourself and the person you are in relationships (past or current)?

Leave blank if not relevant.
Have you had any previous traumatic or emotional relationships?*

YesNo
Do you feel supported by your partner, friends and family?*

YesNo
Please list the people around you that support you?*
Spouse, children, parents, friends, health professional, coach, neighbour etc.
Do any relationships in your life currently cause you stress?
Include partner, friends, family, work colleagues, etc.
How would you rate your childhood and upbringing in relation to support, care and nurture?*
Environment
Please tell me where you spend most of your time?
At home, work, outside, training, travelling etc
Do you enjoy spending time alone and in your own company?
Does your environment support you in terms of your daily routine (current or desired) and life aspirations?

YesNoIn some waysOther
Are there any aspects of your environment that aren't beneficial to you and your goals?
Pleas check which of these describe your home environment.

Natural lightReal plantsBedroom (for sleeping & sex only)A calm spaceTidy spacesUnorganised spacesNo space to spend time aloneOutdoor areaNearby to natureOver-crowdedOther
Readiness for change
Over the next month I am going to achieve...*
Over the next 6 months I am going to achieve...*
Over the next 12 months I am going to achieve...*
Over the next 5 years I am going to achieve...*
What has happened to your health and performance over the past 1-3 months?
What has happened to your health and performance over the past 6-12 months?
What has happened to your health and performance over the past 1-5 years?
What lagging areas do you have which you'd like to improve in relation to your health and performance?*
Ho ware you going to measure and keep accountable to your performance goals?*
Please rate your readiness for change.*

12345678910
How READY are you to change behaviours and habits which are not serving you?*
How WILLING are you to change behaviours and habits which are not serving you?*
How ABLE are you to change behaviours and habits which are not serving you?*
To proceed with coaching services with We Glow Wellness, please read the disclaimer below followed by agreeing to the terms.

o   This program is not intended to diagnose, treat, prevent or cure any disease or condition.

o   I do not practice medicine and I do not diagnose nor treat diseases or medical conditions.

o   It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed medical professional.

o   As your wellness coach I do not provide a second opinion or in any way attempt to alter or influence the treatment plans or therapeutic goals/recommendations of your personal physician.

o   It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.

o   I shall not be liable or responsible for, and you hereby release me from any loss, claim, liability or damage allegedly arising from any information or suggestion made during any consultation between us or from any material or content found in this website, including but not limited to articles and blogs.

o   The information discussed during your consultation is purely for educational purposely only.

o   Prior to working together, I require you state that you have read, understand and comply with the above.
I have read the above disclaimer and agree to the Terms & Conditions.
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WE GLOW

Holistic Health Analysis

Health

Dental

Mindset

Women's Health

Symptom Guide

Digestion

Movement

Nutrition

Relationships

Environment

Readiness for change