Health coaching intakePlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Personal InformationNameFirstLastDate of BirthPhone NumberMailing address:GenderEmail AddressEmergency contact name/phone number:Medical HistoryCurrent Health ConditionsAllergiesCurrent Medications/SupplementsPrevious SurgeriesDietary InformationCurrent Dietary PatternDietary RestrictionsWeight Loss/Gain GoalsHeightFood PreferencesCurrent WeightHave you ever had an eating disorder? If so, please describe:Lifestyle and Eating HabitsSmoking HabitsNon-smokerSmokerExercise Routine and Frequency/typeCaffeineRecreational drug use, type/frequencyAlcohol ConsumptionDailyWeeklyMonthlyOccasional Social DrinkerMeal FrequencyFluid IntakeEnergy Selected Value: 0 On a scale of 1 - 10 what is your average energy level? 1 is lowest, 10 is highest.Sleep Quality Selected Value: 0 On a scale of 1-10, how is the quality of your sleep?On average, how many hours of sleep do you get each night?OccupationDo you enjoy your work?How many hours per week do you work?Rate your level of stress: 10 is highest, 1 is not a care in the world: Selected Value: 0 How many hours/week do you engage in recreational activities/play and what type?Before your session, please think about what health-promoting, life-giving behaviors you want to do consistently. Feel free to jot your thoughts down here:Please share anything else that would be helpful for me to know before we begin our coaching sessions:Submit