Evaluate & Transform Your Optimal WELLth w/Christine Belcastro

Please fill out the information under each section, especially if you have particular medical or health issues.

This will help me meet you where you & best to assist you in your journey to Optimal WELLth.

Let's reconnect to your body wisdom & reclaim your most authentic life together.

Thank you for entrusting me to be your guide on this personal journey to Optimal WELLth.

xox Christine
Evaluate & Transform Your Life— Live Your Fulfilled Life of Optimal WELLth

Nothing sparks my joy like helping others reclaim their most authentic life.
Name
Phone
Format: (000) 000-0000.
Email
Preferred Method of Contact
Address

Street Address

CityState / Province

Postal / Zip Code
Referred From?
STEP 1: AWAKEN
1. What would like to accomplish with your health? This could be weight-loss, improved sleep, better response to stress, etc.
2. What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?
4. Tell me about your health: Do you have any allergies or medical conditions that could influence which technique we choose?
5a. Are you Pregnant?
5b. Are you Nursing?
6. Are you taking any:

Other
7. Do you have any of the following:

Other
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the Client and monitor. Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication. Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
STEP 2: DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
MOVEMENT
How would you describe the quantity & quality of the activity you do each week?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
What types of physical activity do you enjoy?
MIND
On a scale of 1-10, how fulfilled are you?
On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?
FOOD & HYDRATION
How many meals and snacks do you eat per day?
When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
WEIGHT MANAGEMENT
Age
Height
How much do you currently weigh?
What would you consider to be a healthy weight for you?
Have you tried to lose weight in the past?
What has been difficult for you about losing and maintaining weight?
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surrounds? (This includes: healthy friendships, supportive family, keep junk food in the house, etc
Is there anyone in your life who would like to get healthy with you?
Is there anything else you think I should know about your health?
Should be Empty:

Evaluate & Transform Your Life— Live Your Fulfilled Life of Optimal WELLth

SLEEP & ENERGY

MOVEMENT

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS