Let’s Connect

During your free 30-minute discovery session we will discover what’s been preventing you from reaching your health goals and develop a powerful vision for living your healthiest, best life ever.

Please complete a health history form when you schedule your free 30-minute consultation.

Schedule here

Women's health history form

Name

First Name

Last Name

Phone

(###)

###

####

What is your preferred method of communication?

Age:

Birthdate:

Place of birth:

Height:

Current weight:

Weight six months ago:

Weight one year ago:

Would you like your weight to be different?

If so, what would you like your weight to be?

Relationship status:

Where do you currently live?

Where are you from?

Children?

Any pets?

Occupation:

How many hours per week?

Please list your main health concerns:

Other concerns or goals?

At what point in your life did you feel your best?

Any serious illnesses, injuries or hospitalizations?

How is or was the health of your mother?

How/is the health of your father?

What is your ancestry?

Blood type?

How is your sleep?

How many hours?

Do you wake up at night?

Why?

Any pain, stiffness or swelling?

Constipation, diarrhea or gas?

Allergies or sensitivities?

Are your periods regular?

How many days is your flow?

How frequent?

Painful or symptomatic?

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?

At what point in your life were you feeling your best?

Why, what was different?

What foods did you eat often as a child? What was a typical breakfast, lunch and dinner?

What is your food like these days? What is a typical breakfast, lunch and dinner?

Will family and friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

What percentage of your food is home-cooked?

Where do you get the rest of your food from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

How many alcoholic drinks do you consume per week?

Do you currently use Cannabis and/or CBD>

Are you open to or interested in learning about cannabis &/or CBD?

The most important thing I should do to improve my health is:

Anything else you would like to share?

Men's Health History Form

Name

First Name

Last Name

Phone

(###)

###

####

Preferred method of communication:

Age:

Date of birth:

Place of birth:

Height:

Current weight:

Weight six months ago:

Weight one year ago:

Would you like your weight to be different?

If so, how?

Any current or previous serious illnesses, hospitalizations, or injuries?

Relationship status?

Children?

Any pets?

Occupation:

How many hours do you work per week?

What are your main health concerns?

Any other concerns and/or goals?

At what point in your life did you feel the best?

How is or was your mother's health?

How is or was your father's health?

What is your ancestry?

What is your blood type?

How is your sleep?

How many hours do you sleep per night?

Do you wake up during the night? If so, why?

Any pain, stiffness or swelling?

Any constipation, diarrhea, or gas?

Any allergies or sensitivities?

Are you involved with any healers, helpers or therapies?

What role do sports and exercise play in your life?

At what point in your life were you feeling your best?

Why, what was different?

Will your family and friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

What foods did you eat often as a child? What was a typical breakfast, lunch and dinner?

What foods do you typically eat these days? What is a typical breakfast, lunch and dinner?

What do you typically drink during the day and in the evening?

What percentage of your food is home-cooked?

Where does your non-home cooked food come from?

Do you crave sugar, caffeine, or cigarettes? Do you have any other major addictions?

How many alcoholic beverages do you consume per week?

Do you currently us cannabis and /or CBD?

Are you open to or interested in learning about cannabis &/or CBD?

The most important thing I should do to improve my health is:

Is there anything else you would like to share?

Coachability Index

Name

First Name

Last Name

Please score each statement on a scale of 1-5 (1 is the least true and 5 is the most true). As a health coach, my job is to assist you in developing and achieving goals. In order to do this, you play a major part in the process. To determine if health coaching is a good fit for you, please answer the following questions:

Got it!

I desire greater clarity and wellness in my life.

I keep my word without struggling or sabotaging.

I am willing to be accountable to another person.

I am open to new ideas and new ways of reaching goals.

I realize there are no “magic bullets” and the only answers for me will be coming from my own discovery experience.

I am willing to take the action necessary to achieve my goals.

I am open to talking about my history, health, and goals.

I can be relied upon to be on time for all calls and appointments.

I will be honest with my coach and trust that my coach will have the skills to gently guide me to where I need to be.

I am someone who can “share the credit” for my success with my coach.

I recognize that coaching is not counseling, consulting or mentoring.

I am willing to acknowledge coaching as a partnership that will help me produce fulfilling results in my personal and professional lives.

I am ready to evolve, to increase my sense of wellbeing and to live a healthy lifestyle.

I can identify two or three things I would like to change in my life.

I am ready to move from dwelling in the challenges to taking proactive, positive action.

I am willing to acknowledge my limiting beliefs that block me from reaching my goal.

I am willing to stop or change the self-defeating behaviors that limit my success.

I am fully willing to do the work and let the coach do the coaching.

I am also willing to enlist the support of others who care about me to speed my progress without relinquishing responsibility for my own life decisions and action.

I am willing to see coaching as a worthwhile investment in my life.

SCORING KEY: <45 Not Coachable right now. 46 - 55 Coachable, but you may need to ensure that the coaching agreement and boundaries are thoroughly understood and honored. 56 - 65 Easily Coachable. >75 Extremely Coachable. Please type your score in the field below.