Health Blueprint

  • Health Blueprint

  • Personal Details

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  • A few things before you get started with the Questions

    This is a very comprehensive questionnaire, it will take 15 - 20 minutes to complete fully so please set some time aside before starting.

    Please try to answer all questions as best you can. The more information you can supply the better we can understand your individual situation and structure recommendations more effectively.

    Please dont worry if you cannot think of a specific answer to any of the questions, there is no right or wrong answer, Just put whatever comes to mind, any information can help even if you think it may not be relvent to the question.

    Please take your time to fill in this form, you are welcome to contact me if you have any quieries regarding some of the questions and I will be happy to advise.

    If you are really unsure please type "I am unsure about this question" and we can discuss it further on our next call.

  • About You

    The questions within this section are aimed at understanding what your current lifestyle consists of, including things such as family responsibilities, current job role/work routine etc.
  • Which of these statements best describe your current job. (please tick all that apply)

  • Sleep

    The following questions are aimed at understanding your current sleep routine/habits
  • On an average night, how many hours are you usually in bed?*
  • On an average night, how many hours of sleep do you normally get?*
  • Please tick all boxes that apply to you.*
  • Do you wake up with a Dry Mouth in the morning or during the night?*

  • Food/Nutrition

    The following questions are aimed at understanding your current Food/Nutrition routine/habits
  • How often do you usually eat Processed or Packaged foods, Fast food or Takeaways?*
  • Do you eat many foods that contain Grains/Flour? (Bread, Wraps, Pasta, Cereal, Cakes etc.)*
  • Do you eat many sugary foods or beverages? (Sweets, Chocolate, Biscuits, Fizzy Drinks etc.)*
  • Do you consume drinks such as Fruit Juices, Energy Drinks or Sports Drinks? (Orange/Apple Juice, Red bull or Lucozade etc.)*
  • Do you ever feel hungry between meals?*
  • Do you ever feel Shaky, Light Headed or lose Concentration between meals?*
  • Do you ever find yourself snacking between meals?*
  • Except Water, how close to sleep do you usually Eat or Drink anything?*
  • Tea/Coffee: Please select all of the most relevant answers.

  • Gut Health

    These questions are to help highlight any potential issues with the Gut or Digestion
  • Please tick the most relevant answer for each topic related Gut Health*
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  • Exercise/Movement

    The following questions are aimed at understanding your current activity level.
  • Do you Recover well from exercise? (Muscles aches, DOMS etc)*

  • Health Questions - Current Health

    The following questions are aimed at assessing your current health, energy levels and stress.
  • Please tick all options that apply to you*
  • Do you smoke or drink alcohol regularly?*
  • Do you feel cold easily or struggle to keep warm?*
  • Have you ever? (Please Tick all that apply.)*
  • Have you had any of the following Dental Surguries*

  • Bio-Feedback Markers

    These questions give me insight into what signs your body may be giving you about your health.
  • SKIN - Do you regularly experience any of the following signs?*
  • FINGER NAILS - Do you regularly experience any of the following signs?*
  • NOSE - Do you regularly experience any of the following signs?*
  • EARS - Do you regularly experience any of the following signs?*
  • EYES - Do you regularly experience any of the following signs?*
  • MOUTH - Do you regularly experience any of the following signs?*
  • HAIR - Do you regularly experience any of the following signs?*

  • Life Events

    Some of these questions might seem random for a lifestyle questionnaire but they may help highlight the reasons for your choices and behaviors. Try and answer these questions as thoroughly as possible.
  • Did you suffer any Trauma as a child?
  • Which of these apply to your early life as a child?
  • Have you experienced any of the following as an Adult?

  • Goals/Coaching

    The following questions are aimed at understanding your goals and what you are looking to gain from this coaching relationship and beyond
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