Please fill the form. All of your information will remain confidential between you and the Health Coach.
Select A Program Master ClassIntroductory ClassSugar-free Program
Select Your Gender MaleFemale
First name
Last name
Email address
How often do you check email?
Phone
Home
Work
Mobile
Age
Height
Date of Birth
Place of Birth
Current weight
Weight 6 months ago
Weight one year ago
Would you like your weight to be different?YesNo
Is So, what?
Relationship statusMarriedSingleIn a relationship status
Where do you currently live?
Children
Pets
Occupation
Hours of work per week
Please list your main health concerns
Other concerns and goals
At what point in your life did you feel best?
Any serious illnesses/hospitalizations/injuries?
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
What blood type are you?
How is your sleep?
How many hours?
Do you wake up at night?YesNo
If yes, why?
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas? Please mention
Allergies or sensitivities? Please explain
Are periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain
Reached or approaching menopause? Please explain
Birth control history
Do you experience yeast infections or urinary tract infections? Please explain
Do you take any supplements or medications? Please list
Any healers, helpers, or therapies with which you are involved? Please list
What role do sports and exercise play in your life?
What foods did you eat often as a child? Breakfast Lunch Dinner Snacks Liquids What is your food like these days? Breakfast Lunch Dinner Snacks Liquids
Do you cook?
What percentage of your food is home-cooked?
Where do you get rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is
Anything else you would like to share?
