Health Assessment – Love Nutrition Coaching

Are you interested in assessing your current health? Please fill out this assessment. You may schedule a free phone consultation to discuss your results with me. I’ll be able to give you an idea of what changes you may like to make and we can discuss if my services are a good fit for you.

All of your information will remain confidential.

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PERSONAL INFORMATION: Name *

First

Last

Email *

Phone number *

Preferred communication method *

Age *

Relationship Status *

City of residence *

Height *

Weight *

Occupation *

Hours of work per week *

WELLNESS INFORMATION: Please list your main wellness concerns: *

Please list your top wellness goals: *

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

Any serious illnesses, hospitalizations or injuries? *

How is your sleep? *

How many hours of sleep do you get each night? *

Do you wake up at night? *

Any pain, stiffness, or swelling? *

How's your digestion? *

Allergies or sensitivities? Please explain: *

OTHER INFORMATION: Do you take any supplements or medications? Please list: *

Any healers, helpers or therapies with which you are involved? *

What role does exercise play in your life? *

FOOD INFORMATION: What foods did you eat often as a child? *

Breakfasts, lunches, dinners, snacks, liquids

What foods do you eat often today? *

Breakfasts, lunches, dinners, snacks, liquids

Will family/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 from? *

Do you experience cravings? If so, what? *

The most important thing I can do to improve my/my family's wellness is: *

ADDITIONAL COMMENTS: Please list anything else you'd like to share:

Your answers will be submitted to Love Nutrition Coaching.

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