This form will take approximately 15-20 minutes to complete. All of your information will remain confidential between you and the health coach. Once this form is received, you will receive an email to schedule your 30-minute health consultation over the phone.
Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Birthdate
-
Month
-
Day
Year
Date
Place of birth?
Height
Weight
Would you like for your weight to be different?
Yes, lower
Yes, higher
No, I am happy to maintain
Relationship Status
Children?
Where do you currently live?
Pets in the household?
What is your occupation?
How many hours per week do you work?
Have you live or traveled outside of the U.S. in the last year?
Yes
No
Please list your main health concerns
What treatments have you tried (healers, helpers, therapy, chiropractor, acupuncture)? Have you found any to be successful?
At what point in your life did you feel your best?
Have you or your family recently experienced any major life changes? If so, please share.
How is your sleep at night? How many hours? Do you wake up at night?
Do you have any pain, stiffness or swelling?
How often have you taken antibiotics?
What supplements, vitamins or herbs are you currently taking?
What prescriptions are you currently on?
Do you have any known allergies or sensitivities? These can be for food or environmental.
If you have a period, are they regular? How many days is your flow? How frequent?
What do you typically eat for breakfast? What time each day?
What do you typically eat for lunch? What time each day?
What do you typically eat for dinner? What time each day?
What do you typically eat for snacks or dessert?
How many cups of coffee/ caffeine do you have each day?
0
1
1-2
2-3
More than 3
How many times each week do you drink alcohol?
Do you consume diary? Whether cooking, in coffee, baking, snacks, meals
Yes
No
Do you consume gluten?
Yes
No
Do you consume sugar (not fructose)?
Yes
No
Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc? If yes, are these symptoms associated with a particular food or supplement?
Do you intermittent fast? If so, how many hours?
How many bowel movements do you have each day?
Do you have any of the following?
Constipation
Diarrhrea
Straining
Inestinal Gas
None of the above
Do you have mercury amalgam fillings in your teeth? If so, how many?
To your knowledge, have you been exposed to toxic metals or mold in your job or at home?
How would you describe your current level of stress?
How would you describe the relationship with food and your body as it is right now?
Do you exercise regularly? If so, how many times each week? What type of exercise?
The most important thing I should do to improve my health is:
Why do you believe you would be a good candidate to work with?
The information in this form contains information intended only for the use of the health coach, Molly Flynn. Information Included in this form is for health education purposes only and is not intended to diagnose, treat, cure or prevent any disease. Please consult with your medical practitioner before making any changes to diet, exercise or adding supplements. To acknowledge your receipt of this disclaimer, please type your name below.
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