Intake form new clients only First Name Last Name Email Phone (###) ### #### DOB Current weight: Weight one year ago: Relationship status: Children: Pets: Where do you currently live? Occupation: Hours of work per week: Health Info Please list main health concerns: Other concerns / goals? At what point in your life did you feel the best? Any serious illness / hospitalizations / injuries? How is/was the health of your mother? How is/was the health of your father? How is your sleep? On average how many hours do you sleep per night? Do you wake up at night? Any pain / stiffness / swelling? Allergies or sensitivities? Please explain: Womens Health Are your periods regular? yes no On average how many days is your flow? Painful or symptomatic? Please explain: Reached or approaching menopause? Please explain: Birth control history? Are you currently on it? If no, when did you stop? What kind? For how long? Do you experience yeast infections or utis? Please explain: Medical Info Do you take supplements or medications? Please list: Any healers, helpers, or therapies you are involved with? Please list: What role do sports and exercise play in your life? Food Info What foods did you often eat as a child? Breakfast, lunch, dinner, snacks: What is your food like these days? Breakfast, lunch, dinner, snacks: Will your family & friends be supportive of any food and/or lifestyle changes? yes no i'm not sure Do you cook? What percent of meals are home-cooked? Where do you get the 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... On a scale of 1-10 how ready are you to invest in your health? Are you financially able to commit to a 1:1 coaching program at this time? ranging from $200-$350/mo yes, I plan to pay in full yes, but i'll need a payment plan no, I'd like to discuss further options Thank you!