Congratulations on taking a step toward aligned, nourished, and radiant health for yourself and your loved ones.
Please note most responses are optional, your comfort and consent are essential.
Personal Details
Let's start by getting to know you
Full Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Helps us adjust our recommendations by taking into account your lifestyle
Which services are you interested in exploring?
*
Personal Health Coaching
Family Wellness Coaching
Mental and Emotional Health
Nutrition and Lifestyle
Grocery Store Tour & Nutrition
Detox Support/Gut Reset
Anxiety, Chronic Stress
Other (please specify)
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Current Health Snapshot & Focus Areas
Help us understand your current baseline
Weight (lb)
Height (cm)
What are your current primary health concerns?
*
Mood/Depression/Anxiety
Low Energy or Fatigue
Digestive Issues/Bloating/Sensitivities
Chronic Stress
Hormone Imbalance
Skin Concerns
Weight/Body Image
Other
How Many Hours of Sleep Do You Usually Get?
Please Select
8 Hours +
6-8 Hours
4-6 Hours
Less than 4 Hours
If you experience irregular sleep, please let us know by describing your circumstances at the end of the questionnaire.
Rate Your Sleep Quality
Please Select
1
2
3
4
5
1 (Poor) - 5 (Excellent)
How Often Do You Exercise or Move Your Body Each Week?
Please Select
Not at all besides moving around for tasks
Some movement, yoga, running
Strenuous exercise once a week
Strenuous exercise twice a week
Strenuous exercise every other day
Describe Your Current Diet/Eating Habits in a Few Words:
Do You Drink Alcohol or Smoke? If Yes, How Often and How Much?
Pain Points: Are you experiencing any physical discomfort or symptoms? List up to 3 with a short description and rate severity (1-5)
Symptom 1: ____________ Severity [1-5]
Symptom 2: ____________ Severity [1-5]
Symptom 3: ____________ Severity [1-5]
Readiness & Commitment
Please Select
I'm fully committed and ready now
I'm curious but need a little guidance
I've tried before and want this time to be different
I want support to help my family feel better
I'm ready for a mindset and lifestyle shift
How ready are you to take aligned steps toward your wellness goals?
Your Wellness Goals
What would you love to experience more of?
*
Confidence
Balanced Mood/Emotional Regulation
Better Digestion, No more Bloating
Restful Sleep
Feeling Confident in Your Body
Clear, Glowing Skin
Less Stress & Anxiety
Nourishing Routines
Joyful Eating & Food Freedom
Connected, Healthier Family Life
Other
Appointment
Preferred Day/Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Time
Hour Minutes
AM
PM
AM/PM Option
Schedule of the first appointment
Are you currently seeing a therapist or coach?
Yes
No
Do you have any allergies? If yes, please list them below:
Are you currently taking any medications or supplements? If yes, please identify the type and purpose:
*
Please check below if you have any of the current health conditions:
Rows
Present
Remarks
Gastrointestinal
Respiratory
Cardiovascular
Neurological
Dermatological
Musculoskeletal
Urinary
Reproductive
Metabolic
Endocrine
What are the ways you manage stress?
What relaxation techniques do you employ?
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Terms and Conditions
I confirmed that all information in this form is accurate to the best of my knowledge.
Practitioner and I understand the information in this form is confidential.
The services provided are for educational and wellness purposes only and are not intended to diagnose, treat, cure, or replace professional medical advice or care. Please consult your healthcare provider regarding any medical concerns.
I agree to take full responsibility for your choices and actions. The practitioner is not liable for any outcomes resulting from the use of these services.
I understand that specific results or outcomes are not guaranteed.
Client Signature
Date Signed
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Month
-
Day
Year
Date
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