Food and Lifestyle Assessment Form

For a brief overview of your current diet and lifestyle, please fill out this form with as much detail as possible. All information is confidential. This information will help me to evaluate a starting point for our coaching sessions together and to help me to help you best.

Note: A parent or guardian must fill out this form for minors under the age of 18.

(Please Note As Many Examples of Each As You Can Recall) Fruits:
Are there any digestive system issues? This will include: Lactose Intolerance, Gluten Intolerance, Gastroesophageal Reflux Disease (GERD), Irritable Bowel Syndrome or any type of Inflammatory Bowel Disease including ulcerative colitis and Crohn’s disease or any other similar type of issue that needs to be known by your health coach:
What is your desired outcome or reason(s) for having a health coach (improve your health, more energy, lose weight, specific ailment, etc.)? Feel free to elaborate:
What do you do for exercise (all activities)?
How many days a week do you move your body with more energy than a leisurely walk? This will include all sports activities:
What do you consider “stressors” (or what makes you unhappy) in your life today?
How many hours of uninterrupted sleep are you getting each night?
What are your absolute most-liked and desired foods to eat for meals?
Please list all that you feel comfortable:
Please list:
Please explain:
Please explain:
or Questions About Nutritional Health or Weight Loss? Please explain:
SUBMIT
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