You are one decision away from your best life yet!
Congratulations on taking your first step towards feeling your best in mind, body, and spirit! Please provide as much information as you can on particular medical or health issues. This will help provide insight into how we can partner together.
Health Profile
Pamela Kanda Coaching
Name
*
Phone
*
Format: (000) 000-0000.
Email
*
Preferred Method of Contact
*
Address
*
Street Address
City
State / Province
Postal / Zip Code
Referred From?
STEP 1: AWAKEN
1. In what ways would you like to feel better in your health and wellness? This could be feeling physically and mentally better in general, more fulfillment, improved sleep, better response to stress, etc.
*
2. What is your main motivation for wanting to work with a coach to support you with any of the above?
*
3. Can you tell me about a time in your life when you felt your best? What has changed between then and now?
*
4. Tell me what has not worked and why.
*
6. Are you taking any medication or any herbs or supplements for:
Diabetes
High Blood Pressure
Lithium*
Thyroid
Coumadin (Warfarin)
Other
7. Do you have or experiencing any of the following:
High Blood Pressure
Diabetes - Type 1
Diabetes - Type 2
Gout
Gluten Allergy or Intolerance
Soy Allergy or Intolerance
Food Allergy (Medically Diagnosed)
Physical pain or tightness (back, knees, shoulders, etc.)
Inflammation in your joints
Other
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the Client and monitor. Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication. Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
STEP 2: DAILY ROUTINE & HABITS
SLEEP & ENERGY
On a scale from 1-10, rate your quality of your sleep. 10=sleeping beauty
How many hours of sleep do you get in a typical night?
*
On a scale of 1-10, what is your energy level throughout the day? 10=energizer bunny or completely wide awake
*
MOTION
In what ways do you actively move throughout the day? Walking, standing, exercise,etc.
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
*
What types of physical activity are you enjoying the most right now?
MIND
On a scale of 1-10, how fulfilled are you? 10=very fulfilled
*
On a scale of 1-10, how much do you worry? 10=always worry
What area of your life tends to be the biggest stress for you? And in what ways do you manage your stress right now?
What type of work do you do?
*
On a scale of 1-10, how much do you enjoy what you do? 10=Absolutely
*
NUTRITION & HYDRATION
How many meals and snacks do you eat per day?
*
What foods do you enjoy the most?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
*
What, other than water, do you drink? Coffee, soda, alcohol, tea, etc.
How much during any given day? Coffee, soda, alcohol, tea, etc.
PHYSICAL HEALTH
Age
*
Height
*
When was the last time you felt your best physically?
*
What types of services have you invested in to support your physical health? personal training or gym membership, acupuncture, chinese medicine, ayurveda, naturapathic medicine, homeopathy, reflexology, sound baths, etc.
*
What has worked the most for you and why?
*
What are you interested in learning more about or incorporating into your daily routine?
*
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, accountability buddies, keep junk food in the house, etc
*
Is there anyone in your life who would like to get healthy with you?
*
Is there anything else you think I should know about your health?
*
Submit
Should be Empty: