Renewed & Aligned Intake Form

Name

First NameLast Name

Age

Date of Birth

Date

Gender

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Marital Status

Occupation

What are your top three health and wellness goals?

What motivated you to seek holistic health coaching?

Have you worked with a health coach or wellness practitioner before? If yes, what was your experience?

Health History Do you have any medical conditions or diagnoses

Are you currently taking any medications (over -the counter- or prescription) or supplements?

If yes please list

List any health conditions you have?

Do you have any allergies (e.g. food, environmental, medication)?

Do you have a history of major surgeries or hospitalizations?

Do any members of your family have any medical conditions or diagnosis?

Lifestyle Information Describe a typical day for you, including work, activities, and family responsibilities.

How many hours of sleep do you get on average per night?

Describe your sleep quality.

Do you exercise regularly? If so, what type and how often?

Do you use tobacco, alcohol, or recreational drugs?

If so, please describe use and frequency

Nutritional Data Describe your typical diet, including when, what, and how much you eat and drink throughout the day.

Do you follow any specifice dietary plan(e.g., Vegetarian, Keto, Gluten-free, fasting)?

Do you have any known food sensitvities or intolerances?

How often do you dine out or consume processed foods?

Do you have any cravings or favorites foods?

Are there any foods you dislike? If so, what and why?

How often do you have bowel movements, and do you experience loose stools or constipation?

Emotional & Mental Wellbeing How would you rate your current level of stress? (1-10)

What are the main sources of stress in your life?

How does stress affect your eating habits, sleep quality, or other lifestyle choices?

Do you practice any stress management or mindfulness techniques?

Do you have a support system (friends family ,community)?

Spiritual & Personal Growth Do you have a spiritual practice or belief system that supports you?

What brings you a sense of purpose or fullfilment?

Are there any areas of your life where you feel stuck or unbalanced?

Challenges & Barriers What are the biggest obstacles standing in the way of your health goals?

Describe your past attempts at change, including success and failures.

Describe any barriers, such as being unsure of where to start or self- doubt.

What are your biggest fears or worries about making lifestyle changes?

Additinal Information What are your expectations from our coaching relationship?

Is there anything else you would like me to know?

Coaching Agreement & Acknowledgment

At Renewed & Aligned, my goal is to support you in a way that honors your body, your season of life, and your overall well-being.

By submitting this form, you acknowledge and agree to the following:

I understand that health coaching is not medical advice, diagnosis, or treatment.
I take full responsibility for my health decisions and actions.
I agree to show up honestly and consistently to get the most out of this experience.
I understand that results are not guaranteed and depend on my own effort and consistency.
All information shared will remain confidential.
By checking the signing below, I acknowledge that I have read and agree to the terms above.

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