Health Coaching - Intake Form

Please fill out the following form to help us understand your physical condition.

On a scale of 1 to 5, 5 being extremely stressful, what is your stress level from your occupation?
On a scale of 1 to 5, 5 being extremely stressful, what is your stress level from your home life?
Rate your non-exercise movement from 1 to 5; 1 being very sedentary, 5 being a movement-rich daily life.
Check all that apply:
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What is the quality of your sleep?
Do you wake frequently?
What type of water do you drink? (Check all tha apply)
Are smoothies a regular part of your diet?
Do you avoid processed food?
Do you use artificial sweeteners?
When shopping for food, do you make it a priority to buy local or organic food?
On a scale of 1 to 5, how would you rate how well you feel in an average week? With your scale ranging from: 1 - "I feel very poorly" to 5 - "I sustain optimal health for the most part."
On a scale of 1 to 5, how would you rate your energy in an average week? With your scale ranging from: 1 - "I can barely get out of bed" to 5 - "I crush it all day, every day."
Do you have a pacemaker or any other electrical device supporting your health?
Do you have any metal implants?
Have you had any organs removed or an organ transplant?
Do you get sick often throughout the winter, or the rest of the year, with colds and flu-like symptoms?
Are you currently in therapy/counselling?
Do you need additional support to boost your immune system?
Are you on any medication for depression or anxiety?
Do you feel ready and willing to commit to do the work it takes to transform your health?

Thanks for submitting!