Health Consultation

Full Name* This field is required.

First Name

Last Name

Where are you from?* This field is required.

City

State

Country

Phone Number* This field is required.

Area Code

Phone Number

E-mail* This field is required.

Name of the person who referred you* This field is required.Enter N/A if this does not apply to you

My focus is to help clients to reach their goals physically, mentally and financially. Which of these is your main focus in reaching out today?This can change over time, choose what you are most concerned about as of today.

Physical

Financial

Mental

All of the above

I am interested in...Select all the apply

Sleep better

Move more

Eat healthier

Improve energy levels

Learn stress relief mechanisms

Improve my relationships

Have healthier surroundings

Looking for support

Lose weight

Tell me more about what you would like to accomplish with your health* This field is required.(Weight loss, improved sleep, better stress response, etc.)

What is your main motivation for wanting to make changes to your health?* This field is required.(Relationships, activities, how you will feel, self-confidence, physical goal, etc)

Do you feel that you are READY to make some changes as of today?* This field is required.Readiness is a KEY determinant in your degree of success.

YESNO

Can you tell me about a time in your life when you felt that you were healthier?What has changed between then and now?

Tell me more about your general health concerns* This field is required.Do you have any chronic diseases or diagnoses? If you are of child-bearing age, are you currently pregnant or breastfeeding? List any food allergies here as well.

Do you have any of the following:* This field is required.**We recommend that Clients contact their healthcare provider before starting and throughout their weight loss journey.

High Blood Pressure

Diabetes Type II

Diabetes Type I

Gout

Gluten Intolerance or Sensitivity

Soy Allergy or Intolerance

Food Allergies

NONE

Other

Are you taking any medications for:* This field is required.

Diabetes

Thyroid

High Blood Pressure

Coumadin (Warfarin)

Lithium

None

Other

Tell me about your sleeping habits...How many hours do you routinely sleep? Is it quality sleep?

Do you feel rested and have enough energy to get through your day?Are you able to do what you need to do throughout the day?

What are you doing currently to keep yourself active? Daily exercise, walking, strenuous job, etc

What kind of stressors do you encounter daily or weekly?* This field is required.Work related, home, family, relationship, etc

What coping mechanisms do you have in place currently?

Tell me about a typical day for you in regard to your nutrition habits* This field is required.Do you eat breakfast? How many meals a day? Are you a snacker? Weaknesses?

How many ounces of water do you drink daily?* This field is required.Recommended amount is 64 ounces a day

What beverages other than water do you consume daily?Coffee, tea, milk, soda, alcohol

How many times a week do you eat out?At restaurants, gas station stops, coffee shops, etc

If you are comfortable sharing, what is your current age and how tall are you?

What do you consider to be a healthy weight for you? How far away from that are you currently?* This field is required.This number varies for everyone, there is no right or wrong response!

What do you do for work/career? Do you enjoy what you do?* This field is required.

What have you found to be most difficult about maintaining a healthy weight? What have you tried in the past?

Would you say that the people in your immediate circle of support are...* This field is required.

Healthier than you are

The same level of healthy that you are

More unhealthy than you are

Other

Is there anyone in your life who would like to get healthy with you?* This field is required.Having supportive people in your immediate friend/family circle helps to increase your rate of success!

Are you comfortable with me contacting you regarding your responses above?* This field is required.

YESNO

What is your preferred contact method?* This field is required.Zoom, call, text, email, messenger

What is the best time of day or day of the week to try to connect with you?* This field is required.

Health Consultation