Gut Health Coaching

Gut Health Coaching

Health History Form
Thank you for taking the time to fill out this form and provide me with details of your health, goals and medical history.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender identity
Preferred Pronouns
Relationship Status
Occupation
Hours per week
Referred By:

Social mediaGoogle searchFriend/familyPhysicianOther
if you selected 'other', please tell us how you heard about us:

Statistics
Age
Current weight
Ideal weight
Family/Living Situation
Children
Exercise/Recreation
History
Have you lived or traveled outside of the United States? If so, when and where?
Have you or your family recently experienced any major life changes? If so, please explain.
Have you experienced any major losses in life? If so, please explain.
How much time have you had to take off from work or school in the last year?

0-2 days3-14 daysMore than 15 days

Health Concerns
What are your top 3 health concerns? (in order of importance to you).
How have you dealt with these concerns in the past? (Doctors, self care, diet, other)
Have you experienced any success with these approaches?
What other health practitioners are you seeing?
At what point in your life did you feel your best?
Any serious illnesses, hospitalizations, and/or injuries?

How often did you take antibiotics in your childhood/teens/adulthood?

List any medications you are currently taking:

	Medicine name	Dosage	Frequency/Route	Duration	Comments
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List all vitamins, minerals, herbs and nutritional supplements you are now taking:

	Name	Dosage	Frequency/Route	Duration	Comments
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Nutritional Status
Are there any foods that you avoid because of the way they make you feel? If yes, please name the food and the symptom:
Do you have symptoms immediately after eating like bloating, gas, sneezing or hives? If so, please explain:
Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches, sinus congestion, etc? If so, please explain:
Are there foods that you crave? If so, please explain:
Do you have any known food allergies or sensitivities?
Which of the following foods do you consume regularly?

sodadiet sodarefined sugaralcoholfast foodgluten (wheat, rye, barley)dairy (milk, cheese, yogurt)coffee

PROGRAM AGREEMENT

Welcome!

During the coming six months, you will learn ways to help yourself achieve a healthier diet and lifestyle. Please read the following. If anything is unclear, please ask.

This Agreement is made today between Cristina Blanco employed by The Teal Center and the person named at the end of this document, [the Client].
The Program in which you are about to enroll will include all of the following:
Two 60-minute appointments each month for six months, which will include a discussion of your progress, recommendations, guidance and accountability.Email support Monday - Friday between our sessions with a 24 hour turn around response.A variety of handouts, recipes, book suggestions, and other materials as needed.
SCHEDULING

As your Coach, I understand that you, my client, have a busy schedule and I take pride in not keeping you waiting or keeping you longer than planned. Each session will end 60 minutes after it was scheduled to begin. Please be on time. If you need to cancel or reschedule the appointment, you must do so 24 hours in advance; otherwise, you will forfeit that appointment and will not have an opportunity to reschedule it.
Program begins Date and ends Date ("end date")
This program expires if all 12 sessions have not been completed within two months after the End Date specified above.

PAYMENTS AND REFUNDS

You, the Client, understand that the regular cost of the Program is $250 per month for six months. Payments of $250 are due on the first day of each month, and may be made by credit card. In the event of your absence or withdrawal, for any reason whatsoever, you will remain responsible to pay for the remainder of the program. The Coach reserves the right to cancel the program if at any point she feels it is not advantageous for the coaching program to continue. If this happens, you are only responsible for the pro rata share of coaching services received.

DISCLAIMERS

The Client understands that the role of the Health Coach is not to prescribe or assess micro- and macronutrient levels; provide health care, medical services; or to diagnose, treat or cure any disease, condition or other physical or mental ailment of the human body. Rather, the Coach is a mentor and guide who has been trained in holistic health coaching to help clients reach their own health goals by helping clients devise and implement positive, sustainable lifestyle changes. The Client understands that the Coach is not acting in the capacity of a doctor, licensed dietician-nutritionist, psychologist or other licensed or registered professional, and that any advice given by the Coach is not meant to take the place of advice by these professionals. If the Client is under the care of a healthcare professional or currently uses prescription medications, the Client should discuss any dietary changes or potential dietary supplements use with his or her doctor, and should not discontinue any prescription medications without first consulting his or her doctor.

As a Integrative Nutrition Health Coach, Cristina Blanco primarily educates and motivates clients to assume more personal responsibility for their health by adopting a healthy attitude, lifestyle, and diet. While people generally experience greater health and wellness as a result of embracing a healthier attitude, lifestyle, and diet, Cristina Blanco does not promise or guarantee protection from future illness.

The Client has chosen to work with the Coach and understands that the information received should not be seen as medical advice and is not meant to take the place of seeing licensed health professionals.
CONFIDENTIALITY

The Coach will keep the Client’s information private, and will not share the Client’s information to any third party unless compelled to by law.

If the terms of this Agreement are acceptable, please sign the acceptance below. By doing so, you acknowledge that: (1) you have received a copy of this letter agreement; (2) you have had an opportunity to discuss the contents with the Coach and, if desired, to have it reviewed by an attorney; and (3) you understand, accept and agree to abide by the terms hereof.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

CLIENT AGREEMENT

Please read and sign where applicable
I, blanks* give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.
I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk. To mitigate the risk, I agree to wear a face covering at all times during my session.

I also understand:

1. That massage therapy and/or acupuncture
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow;
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
2. That the massage therapists and/or acupuncturists
- do not diagnose illness, disease or any other physical or mental disorder;
- do not prescribe medical treatment or pharmaceuticals; and
- do not perform any spinal manipulations.
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

If I need to reschedule due to illness or Covid exposure, I agree to contact the Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, canceled, or rescheduled with less than 24 hours notice.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

POLICIES

Welcome! Thank you for choosing The Teal Center!

Please read and initial each of the following:
initials* Appointments missed, cancelled, or rescheduled with less than 24 hours notice will be charged 50% of the session fee. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are sent 48 hours prior to the scheduled appointment.
initials*The Teal Center and its practitioners abide by the ethical standards of practice established by their respective certification boards (NCBTMB and NCCAOM). All clients shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, the therapists are instructed to terminate the session; payment will be made in full by the client and The Teal Center reserves the right to prohibit the client from returning to The Teal Center.
initials*If you have a cold or other contagious illness, please call us before your appointment so we can check with your therapist to see if it is appropriate for you to come in.
initials*In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.
initials*Tips are appreciated but never expected. If you wish to leave a gratuity for your therapist we ask that you do so in cash or by check made directly to the therapist. Gratuity is also available via Venmo app for some therapists.
initials*If you move or change phone numbers, it is your responsibility to inform us. This is important so we can reach you in case of any emergency or any necessary and unforeseen schedule changes.
initials*The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.
Should be Empty:

	Breakfast	Lunch	Dinner	Snacks
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	Symptoms	Chosen treatment(s)	Dates	Past	Now
Irritable bowel syndrome
Crohn's
Ulcerative colitis
Gastritis or Peptic ulcer disease
GERD (reflux or heartburn)
Celiac disease
SIBO
Gut infections
Dysbiosis
Leaky gut
Food allergies, intolerances or reactions
Gallstones
Known absorption or assimilation issues
other

	Past	Now
Type 1 diabetes
Type 2 diabetes
Metabolic syndrome
Insulin resistance or pre-diabetes
Hypothyroidism (low thyroid)
Hypothyroidism (overactive thyroid)
Hashimoto's (autoimmune hypothyroid)
Grave's disease (autoimmune hyperthyroid)
Endocrine problems
Polycystic ovarian syndrome (PCOS)
Infertility
Weight gain
Weight loss
Frequent weight fluctuations
Eating disorder
Menopause difficulties
Hair loss
other

	Past	Now
Osteoarthritis
Fibromyalgia
Chronic pain
Sore muscles or joints, undiagnosed
other

	Past	Now
Chronic fatigue syndrome
Rheumatoid arthritis
Lupus SLE
Raynaud's
Psoriasis
Mixed connective tissue disease (MCTD)
Poor immune function (frequent infections)
Food allergies
Environmental allergies
Multiple chemical sensitivities
Latex allergy
Hepatitis
Lyme (and co-infections)
Chronic-infections (Epstein-Barr, Cytomegalo-virus, Herpes, etc.)
Other

Gut Health Coaching

Thank you for taking the time to fill out this form and provide me with details of your health, goals and medical history.

Statistics

History

Health Concerns

Nutritional Status

Intestinal Status

Medical Status

Hormones/Metabolic

Musculoskeletal/Pain

Immune/Inflammatory

Respiratory Conditions

Skin Conditions

Sleep History

Mental Health Status

Other

Thank you for taking the time to fill out this form! I look forward to working together to achieve optimal gut health!

	Past	Now
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Sleep apnea
Frequent or recurrent colds/flus
Other

	Past	Now
Eczema
Psoriasis
Dermatitis
Hives
Rash, undiagnosed
Acne
Skin cancer (Melanoma)
Skin cancer (Squamous, Basal)
Other