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Help me get to know you so I can custom-fit your coaching and plan. Provide the information you feel comfortable sharing. Please be as honest as possible. Your answers will be kept strictly confidential.

First name

Date of Birth * required

Last name

Sex at birth / Gender identity

Email

Phone

Are you pregnant or nursing?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Height

Change

Weight

Time period of change

Was change intentional?

Current diet (if one followed)

Food allergies/intolerances

Current medications

Nutritional supplements

Caffeine, Nicotene, Alcohol, other substances

Other practitioners you work/have worked with/ What for?/ Did it help?/ Okay to discuss your care with?

Occuption (full time/part time/retired)

Physical activity/ Current frequency/intensity/duration

Other stressors (past/present)/ How you currently manage

Bothersome Physical symptoms

Pain

Fatigue/ Weakness

Shortness of breath

Nausea/vomiting

Constipation

Diarrhea

Skin problems

Details/Other

Mental/Emotional symptoms

Depression/ lack of motivation

Anxiety/ stress

Trouble sleeping

Problems with concentration or memory/ brain fog

Low self-esteem/confidence

Addiction

Emotional or disordered eating

Details/Other

Foods you Love (even if you think you shouldn't)

Foods you Hate

Do you enjoy cooking? Why/ why not?

Where and how often do you eat out /get delivery/ take-out?

Where and how do you usually shop for food?

Decribe your current usual eating pattern.

Please decribe any struggles or frustrations you experience around eating. How would you describe your current relationship with food and your body?

What do you hope to change, learn or achieve through coaching?

I declare that the info I’ve provided is accurate

I agree to the Coaching Contractt

Initials

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