Holistic Health Coaching Questionnaire

1
Name* This field is required.
First Name
Last Name
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Email* This field is required.I will be sending your personalised plan to this email
example@example.com
3
Where do you live?eg. London, UK
4
Sex
Male
Female
5
Age
6
AncestryYour birthplace? What is your background? Where are your parents, grandparents or great grandparents from?
7
Your childhood healthAnything significant that you know about from birth, childhood up to teenage years
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Any past surgeries or significant medical events?If yes, write it down in the box
Please Select
Please Select
Yes
No
9
Any existing medical conditions? eg. eczema, diabetes, arthritis etc
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List any medication/supplements and the condition you are taking them forMedication or vitamins, herbs, homeopathic remedies etc
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Do you have any allergies or intolerances?
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Are there any hereditary health conditions in your immediate family (parents, siblings)?
13
Any past surgeries or significant medical events?If yes, write it down in the box
Please Select
Please Select
Yes
No
14
Current Symptoms
Fatigue/Tiredness
Difficulty sleeping/insomnia
Bloating
Constipation
Diarrhea
Headaches
Migraines
Joint pain
Joint stiffness
Muscle aches/soreness
Muscle weakness
Mood swings
Acne
Eczema
Rosacea
Allergies
Sinus problems
Coughing
Wheezing
Shortness of breath
High blood pressure
Hypertension
High cholesterol levels
Struggles gaining weight
Struggles losing weight
Low energy levels
Difficulty concentrating
Brain fog
Anxiety
Panic attacks
Depression
Low mood
Hormonal imbalances
Frequent infections
Frequent illness
Dizziness
Nausea
Vomiting
Heart palpitations
Excessive thirst
Lack of thirst
Frequent urination
Infrequent urination
Cravings
Extreme swelling (eg. hands, feet)
Vision changes/eye discomfort
Balance problems
Hair loss
Excessive sweating
Night sweats
Sexual dysfunctions
Libido changes
Memory problems
Sensitivity to temperature changes
Heartburn or acid reflux
Restless legs or leg cramps
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You can write down any other symptoms below or expand on the selection from aboveeg. frequency, severity etc.
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Describe your body shapeIf unsure, ask someone to help you
Strong or broad
Heavy
Thin
Weak
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Select one that's closest to your body shapeIf unsure, ask someone to help you
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Here you can upload a picture of yourself, if you preferMake sure your full body is in the frame
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Face tone
White/Pale
Red/Flushed
Green-Blue
Yellow
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Hair and scalp health
Thin
Falling out
Dry
Itchy
Dandruff
Oily
Healthy
21
Regarding hot and cold
I always feel cold
I always feel hot
I thrive in cold conditions
I thrive in hot conditions
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Regarding menstrual health
Regular
Irregular
Excessive blood
Insufficient flow or lack of menses
Very dark blood
Pale and thin blood
Painful
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Digestive healthWrite down anything significant eg. bad taste in mouth, stomach pains, farting etc.
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Sleep healthWrite down anything significant eg. wake up during the night, always tired, can't sleep etc.
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Select the one that sounds similar to youYou don't have to fit the exact description but have more similarities with one than the other
I have a pale or light toned face, I'm quiet and have a slow manner. I feel tired and weak at times. My excretions and secretions are watery and thin. My tongue looks pale, puffy and moist and the moss on top is thin and white. I usually feel cold, especially hands and feet; I love warmth and when I lie down, I curl up. I'm often tired or drowsy. I have a soft and low voice. My breaths are shallow and weak. My pulse feels slow and subtle. Pressure and heat usually relieves my points of pain.
I have a red or flushed face and usually feel agitated, restless and active. I tend to have rapid forceful movements. My tongue looks red or purple and is dry with yellow and thick moss. When I lie down, I prefer to stretch out. I usually feel warm or hot and dislike heat or touch. I often have bad odor and my mouth gets dry - having a desire for fluids, especially cold fluids. My voice is rough and strong and I am talkative. My breaths are deep, rapid and loud. My pulse feels strong and fast. Pressure and heat don't relieve my points of pain.
26
Dietary Preferences
Please Select
Please Select
Omnivore (eats animal products)
Pescatarian (eats fish only)
Vegetarian
Vegan
Other (answer in box)
If other, write down your dietary preferences
27
Describe your typical daily dieteg. what do you eat? do you cook at home? what time do you eat?
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Do you need food inspiration?eg. recipes, home-cooking tips
YESNO
29
Do you smoke?Cigarettes, vape etc
YESNO
30
How would you describe your alcohol consumption?
Please Select
Please Select
Daily
A few times a week
Once a week
Once a month
Once every few months
I don't drink
31
What is your current level of physical activity?
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What is your current level of physical activity?
Inactive/never exercise
Active 1-2 times per week
Active 3-4 times per week
Active daily
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What types of exercise activities do you enjoy?
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How is your sleep quality and duration?
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How is your sleep quality and duration?
I sleep well
I don't sleep well
I have less than 6 hours sleep
I have 7-8 hours sleep
I have more than 9 hours sleep
36
How is your stress levels?
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Are there specific stressors you would like to mention?
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Do you know how to manage stress?
YESNO
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How do you currently manage stress in your life?
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Describe your current work and lifestyle, including working hours, commute, and work environment
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Are there any activities/experiences you would like to be able to participate in or enjoy more fully in the future, but feel limited by your current health or lifestyle habits?
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How do you currently feel, mentally and emotionally?
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Are there any specific areas of emotional well-being you would like to address?
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Have you practiced mindfulness or mind-body techniques before? eg. meditation, yoga etc
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Do you want some mind-body practices to incorporate? eg. meditation, yoga etc
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Would you like some personalised yoga practices?
YESNO
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If you answered yes to the previous question, select your preferences below
Vinyasa
Hatha
Beginner
Intermediate
Deep stretch
Fast paced flow
Relaxing
Challenging
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Do you have any wellness or lifestyle challenges?
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Describe your ideal selfin terms of health, wellness and lifestyle goals
50
Do you lack motivation and inspiration?
YESNO
51
How motivated are you to make lifestyle changes to improve your health and well-being?
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Do you want to be held accountable?
YESNO
53
Are there any particular areas of your life that you feel need the most attention or improvement?
Nutrition
Exercise
Healing
Stress management
Mindset
Habits
Sleep
Other
54
Are you aware of your limiting beliefs?If so, write them down
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Would you like some recommendations on how to overcome limiting beliefs?
YESNO
56
What do you want to be included in your personalised guide?
Healing Guidance
Lifestyle Guidance
Cooking Tips
Wellness Guidance
Recipes
Shopping List
Yoga Sequences
Product Recommendations
Mindset Guidance
Habit Building
Health Tracking
Other
57
If there's anything else that you would like to be included in your personalised guide, write it below
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Is there any other information about your health, lifestyle, or wellness journey that you would like to share?
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Do you have any questions or concerns about the coaching process or what to expect?
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