Pre-Consultation Questionnaire Holistic Health & Wellness Coaching Name * First Last * Last Age: Gender: Preferred Contact Method: Phone Email Text OtherOther Email * Phone: * Occupation: Do you have a predominantly sedentary or active lifestyle? Do you currently exercise? If yes, what type and frequency? Health Concerns: What is your primary health or wellness concern? Are you experiencing any of the following? (Check all that apply): Lack of Sleep Lack of Appetite OtherOther Describe your typical daily diet (include meals, snacks, and beverages): Do you have any dietary restrictions, food allergies, or intolerances? Are you currently taking any dietary supplements? If so, list them: Are you exposed to any of the following environmental or external factors frequently? (Check all that apply): Option 1 Option 2 New Option New Option OtherOther Have you tried any wellness practices before? (e.g., yoga, meditation, reiki, microneedling, red light therapy, etc.) If yes, what has worked for you? What hasn’t? Are you currently taking any medications? (Optional) - If yes, please list them. Do you take any over-the-counter medications, including allergy medication? (Optional) - If yes, please list them. Do you have any known allergies (e.g., food, environmental, medication)? (Optional) - If yes, please list them. Do you have any pre-existing medical conditions or chronic illnesses? Have you undergone any major surgeries in the past 5 years? What specific goals or outcomes are you hoping to achieve from this coaching session? Is there anything else you'd like us to know about your health, lifestyle, or goals before the call? Submit If you are human, leave this field blank.
