Essential Wellness Coach
Assessment Form
Personal Information
Date
-
Month
-
Day
Year
Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Occupation:
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
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
Marital Status
Single
Married
Divorced
Widowed
Living Situation (living alone, with family, friend or housemate.
Back
Next
General Health
Primary Health Care provider (Physician):
Other Health Care provider/s:
Presenting concerns:
Allergies or Sensitivities?
Religious or Spiritual practice:
Surgeries
Yes
No
If yes, please elaborate on what procedures and when. (List each one with dates)
Have you experienced any of the below?
Serious Illness
Motor Vehicle Accident
Falls/Injuries
Covid
Other
How often do you wake at night?
Multiple times a night
Once a night
Irregular Sleep Patterns
Battle to sleep
Do you use a sleep aide or suffer from insomnia? Please elaborate.
How frequently do you exercise?
Multiple times a day
Daily
Weekly
Monthly
Rare to not at all
Please elaborate on what exercises:
Back
Next
Nutrition and Eating Habits
What is your water intake per day?
2 or more litres
1 litre
1 cup or less
What is your caffeine intake per day?
Zero cups
1 cup
2 cups
3 or more cups
Do you smoke?
Yes
No
Please state how often:
Please state how often:
Do you take or use any of the following:
Pharmaceuticals
Supplements
Herbal Medications
Essential Oils/ Floral Essences
Homeopathic
Other
Please list the names of each one with dosages:
Do you have metal , metal fillings, metal plates, stent in your body?
Back
Next
Assessment Form
Please tick relevant boxes, past or present ailments.
Check all that apply (past or present):
Nerves
Reproductive System
Hormonal System
Hepatitis
Bones
Kidneys
Joints
Pancreas
Gall Bladder
Heart Disease
Back
Muscles
Thyroid
Colon
Lungs
Stomach
Other
Do you currently have any of the following skin issues?
Dandruff
Psoriasis
Warts
Eczema/Dermatitis
Acne
Scars
Hair Loss
Herpes Simplex
Athletes Foot
Other
Do you currently have any of the following digestion issues?
Mouth Sores
Gas
Bloating
Diarrhea
Colitis
Irritable Bowel
Vomiting
Nausea
Indigestion
Heartburn
Constipation
Other
Do you currently have any of the following circulation problems?
Heart Palpitations
Shortness of Breath
Tightness in Chest
Blood Clots
Low Blood Pressure
Lymph Edema
High Blood Pressure
Poor Circulation
Fluid Retention
Varicose veins
Other
Do you currently have any of the following nervous system issues?
Depression
Nephropathy
Headaches
Shingles
Sinus
Stroke
Tension
Parkinson's
Migraine
Multiple Sclerosis
Neuralgia
Seizure Disorder
Dementia or impaired memory
Other
Do you currently have any of the following respiratory issues?
Sore Throat
Asthma
Cold
Swollen glands
Flu
Pneumonia
Sinus Issues
Shortness of Breath
Bronchitis
Other
Do you currently have any of the following muscle problems?
Cramps
Jaw pain
Sprains
Inflammation
Arthritis
Spasms
Rheumatism
Back or Joint Issues
Other
Do you currently have any of the following urinary issues?
Frequency
Stones
Kidney Infection
Bladder Infection
Other
Do you currently have any of the following endocrine issues?
Thyroid Dysfunction
Diabetes
Adrenal Dysfunction
Other
Have you ever had cancer? If so, where?
Back
Next
For Women
Have you ever experienced the following:
Menstrual Cycles Regular
Irregular Periods
Menstrual Pain
PMS
Vaginal Thrush
Infertility
Herpes
Endometriosis
Pregnancy
First Trimester
Second Trimester
Third Trimester
Menopausal
Hot flushes
Bloating
Night Sweats
Irritability
Other
Have you ever experienced the following:
Menstrual Cycles Regular
Irregular Periods
Menstrual Pain
PMS
Vaginal Thrush
Infertility
Herpes
Endometriosis
Pregnancy
First Trimester
Second Trimester
Third Trimester
Menopausal
Hot flushes
Bloating
Night Sweats
Irritability
Other
For Men
Have you ever experienced the following:
Infertility
Prostate
Complaints
High Blood Pressure
Colon
Diabetes
Stroke
E.D
Alcoholism
Depression
Other
Back
Next
Have you ever been diagnosed with:
Bacterial Infection
Fungal Infection
Viral Infection
Other
Any other long-term health issue?
Pain (on a scale of 1low-10high)
Emotional Issues:
Anxiety
Depression
Worry
Fear
Anger
Apathy
Empty
Grieving a Loss
Disappointment
Despair
Sorrow
Frustration
Impatience
Apprehension
Powerlessness
Terror
Panic Attacks
Resentment
Remorse
Regret
Lethargy
Listlessness
Boredom
Moodiness
Mood swings
Inadequacy
Unworthiness
Lacking Confidence
Suicidal
Mental Fatigue
Irritable
Other
Mental Issues:
Difficulty in Concentrating
Fear of being alone
Lack of Interest in Life
Constant Irritability
Feeling unable to cope
Dreading the Future
Other
Stress:
Lack of appetite
Unnatural Craving
Constant Tiredness
Frequent Crying or Wish to Cry
Nail Biting
Nervous Twitches
Inability to sit still
Other
How would you rate your stress level?Type a question
Low
Medium
High
Work Conditions
Home Conditions
Self-care activities:
Short-Term Goals
Long-Term Goals
Additional Information
Is there anything else to you would like to add...
Back
Next
Recommendations/ Referrals:
Next Appointment Date
Statement
Scope of Services:I, the undersigned (Client Sign), understand that I am seeking coaching services from Essential Wellness Coach for the purpose of personal development, self-improvement and self-care. These sessions may include discussions related to complementary and alternative medicine and therapies and will be used as case studies. We do not offer once off services, we offer a multiple sessions packaged to serve and transform your well-being.
Indemnity Form
Responsibilities and Acknowledgments: Voluntary Participation: I acknowledge that I am voluntarily participating in coaching sessions and any complementary or alternative therapies or practices discussed or recommended by the coach. Non-Medical Advice: I understand that the coaching services provided by Essential Wellness Coach Loreal Nel are not a substitute for medical or psychological diagnosis, treatment, or advice. The coach does not provide medical, psychological, or therapeutic services. Personal Responsibility: I take full responsibility for my physical and emotional well-being during and after coaching sessions. I understand that I should consult with a qualified healthcare professional regarding any physical or mental health concerns. Confidentiality: I understand and agree that the content of our coaching sessions will be kept confidential, with the following exceptions: (a) if I pose a threat to myself or others, (b) if I disclose information about child or elder abuse, or (c) as required by law. Informed Decision: I have had the opportunity to ask questions and seek clarification regarding any aspect of the coaching process, including the use of complementary or alternative therapies. Indemnity: I release and hold harmless Essential Wellness Coach Loreal Nel, their associates, and any third parties referred to for complementary or alternative therapies, from any liability, claims, demands, actions, causes of action, costs, and expenses arising out of or in any way connected to my coaching sessions. Consent and Agreement: I have read and understand the terms and conditions outlined in this Coaching Indemnity and Consent Form. By signing below, I agree to abide by these terms and release Loreal Nel from any liability associated with my coaching sessions. I (client) take responsibility for my own well-being.
Signature
Submit
Submit
Should be Empty: