Wellness Coaching Questionnaire

Full Name

First NameLast Name

Gender

Age

years

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Height

ft/in

Weight

lbs

What is your desired weight?

Do you have any medication/latex/food allergies? If yes, please list.

List any Medications you take:

List any Supplements you take:

Do You Have any Health Issues:

Have you had any hospitalizations, surgeries, or are missing any body parts (such as gallbladder, appendix, etc)?

Are your menstrual cycles regular?

Are you on birth control?

Are you pregnant?

Are you on hormone replacement therapy(hrt)?

Do you experience symptoms of PMS (cramps, water retention, etc.)

Are you in Perimenopause/ Menopause?

Estimated, about how many courses of antibiotics have you had in your life?

Have you ever had any mercury amalgams or root canals?

How often do you have a bowel movement? How is the consistency and color? (ex:brown, solid)

Have you had any remarkable exposure to toxins such as from your childhood home, work place, living close to an industrial community, pesticides, metals or mold?

At what point in your life did you feel your best and why?

What is your health goal?

What have you tried before and why did it not work for you?

How many hours do you sleep at night?

Do you have difficulty falling asleep, staying asleep, or waking frequently throughout the night?

Rate Your Sleep Quality:

When are you the Most Tired?

Other

Overall how is your energy?

On Average how many nights a week do you get quality sleep?

What do you do for a living?

Whats the activity level at your job?

How many hours per week?

Any major life concerns outside of health and nutrition?

What Stressors do You have?

How do you Cope with Your Stress?

From 0-10 how would you rate your stress level?

What do you do for fun?

On a scale 1-10 how would you define your current diet and why?

What was your nutrition like as a child?

Do you have a mindset or approach when it comes to food?

Do you eat 3 meals a day?

If No, which meals do you skip?

Do you generally snack?

What percentage of your meals are being eaten at home, cooked from scratch?

How many days a week do you eat out?

How much water do you drink daily?

What else do you currently drink?

Please check any of the items that you consume regularly (within the last month)

How many cups of vegetables do you consume per day?

How many servings of grain per day?

How many ounces of protein do you consume per meal?

What are your favorite foods?

Are there any foods that you dislike or that you do not eat?

Do you crave certain foods on a consistent basis?

What are 3 unhealthiest foods that you consume regularly?

Do you experience symptoms after eating meals such as (bloating, belching, vomiting, etc.)

Any history of disordered eating?

From 1-10, how willing are you to make dietary and lifestyle changes?

Do you have family and friends that are supportive of you with making lifestyle and dietary changes?

Other

How many days do you have physical activity outside of work/house hold chores?

What type of physical activity?

Please rate your readiness for change. 10= Ready YESTERDAY!

Why?

What do you need the most help with?

Other

If you could wave a magic wand and change two things in your life, what would they be?

Are you willing to financially commit to changing your life?

How do you prefer to be contacted?

Other

I am so excited that you decided to reach out to me to help you with your wellness goals! I can't wait to work with you! I'll reach out within 48 hours!

Wellness Profile!

Women Only

Sleep Profile

Nutrition Profile

Movement Profile