Sha’Ri Smyth Health Form 💓

So excited at the opportunity to help guide you on such a personal journey. Please take your time when answering. Each response allows me a chance to serve YOU and help you H.E.A.L. THIS IS NOT FOR YOU IF YOU WANT A DIET, FAD, OR QUICK FIX OR WON'T COMMIT TO AT LEAST 6 MONTHS- do you understand? *
Full Name*

First NameLast Name
First off hello 💓 thanks for taking the time to get personal with me. I don't take it for granted. I am a certified holistic health coach with a Masters in health and wellness, currently pursing my Ph.D in health education and promotion. I’m also certified in environmental toxins and gut health, so you are in great hands.
Phone number*
years
Instagram/Facebook contact*
Why do you want to work with me?*
Do you follow a regular working schedule, do you work days, afternoon or nights?*
Please list the physical activities that you participate in.*
If you have any diagnosed health problems list the condition(s).*
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?*

YesNo
Here’s my description of the ideal client. You may suffer from migraines, eczema, allergies, asthma, high blood pressure, or an autoimmune. You may want to regulate blood pressure or cholesterol, gain energy. You might not get good sleep, suffer from lack of eating, over eating or cravings. You may even need better eating habits, to name a few things but you are also just sick and tired of being sick and tired and things not working or you ending back up where you were. You may be also passionate or curious about learning how to reduce and remove toxins from your environment too, because there is ZERO sense in getting the inside healthy if the outside is still creating an unhealthy gut. Is this you?*

YesNo
Do any diseases run in your family?*

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo
If yes please list:
Are you a current cigarette smoker?*

YesNo
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganSeefood- I see food and I eat it 🤪
Explain in more detail
Please rate your readiness for change.*

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What following goals does best fit in with your goals?*

Improved healthReduce toxinsBelly fatFat lossEliminate prescriptionsBetter sleepOther
Other- please explain
What have you tried to reach your health goals? What did you like or not like about what you tried?*
Keto, IF, Restrictive diets, quick fixes, MLMs, medications, procedures. No shame, no judgement... I want to hear what has worked or hasn't.
What are your current eating habits? *
Skip meals, cravings, forget to eat, fast food, over eating...
Are you doing anything currently to move towards your goals? Or are you starting fresh?*

TImeline for achieving your goal.

	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

Are you the sole financial decision maker?*

YesNo
If you are guaranteed to get the results that you are looking for, what would you be willing to invest in your success? *
Please rate your motivational level to do what it takes for reach your goal.

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This journey is for at least six months, you will get to eat (NO SERIOUSLY YOU EAT BOO!), and learn a realistic lifestyle that fits who you are. It isn't easy but it's simple. This program focuses on the science and psychology and what our bodies are designed to do so you can support your body in what it is supposed to do.

If you can’t commit to at least six months or plan to cancel prior this won’t be a good fit for you and that's okay but I want to be realistic.
All sound good to you- please continue.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
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