• Wellness Questionnaire

    Thank you for taking the first step in unleashing a healthier YOU! Kindly complete this form for me so that we can pre-establish a health coaching plan for you. If any of the questions are not applicable to you, please type N/A in the required line. For appointments - book on our app.

  • PERSONAL INFORMATION

  • Date*
     / /
  • Gender*
  • Language preference:*
  • Format: 000 000 0000.
  • Format: 000 000 0000.
  • Format: 000 000 0000.

  • Preferred communication form (email, phone, text)*
  • Is your delivery address the same as your physical address?*
  • How did you hear about Holistic Shift?*
  • Relationship Status:*

  • WELLNESS INFORMATION

  • How is your sleep?*

  • OTHER INFORMATION:

  • Do you take any supplements or medications? (We know the list is long, but we prefer to be as thorough as possible) This list will contribute to part of the wellness consultations, should you sign up for it.*
  • Any healers, helpers or therapies with whom you are involved? *

  • FOOD INFORMATION:

  • Will family/friends be supportive of your desire to make food and/or lifestyle changes?*
  • Do you cook your own food yourself?*
  • Should be Empty: