Private Health Evaluation Form Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *PhoneDate of BirthAgeCurrent weightWould you like your weight to be be different? If so, what?What is your relationship status?Do you have kids? How many?What do you do for work? How many hours per week?Do you have pets?What are your main health concerns?What do you feel are your major blocks from being healthy, successful or doing what you love each day?Are you experiencing physical health symptoms or mental health challenges? Please list them below.What medications and supplements are you currently taking?Any healers, helpers or therapies with which you are involved? Please explain:At what point in your life did you feel your best? What where your habits and lifestyle during that time?Any serious injuries/illness/surgeries or hospitalizations?Have you been diagnosed with any conditions?How is/was the health of your mother?How is/was the health of your father?How is your sleep? Bedtime and wake up time? How many hours /night?Any pain in your body, stiffness or swelling?Do you experience constipation, diarrhea or gas?Are your bowel movements regular?Any allergies or sensitivities? is your menstrual cycle regular?Is it painful or symptomatic? Please explain:Birth Control HistoryDo you experience yeast infections or urinary tract infections? Please explain: Do you have thyroid or hormonal issues?On a scale from 1-10, how dissatisfied are you currently with your state of wellness and energy levels? (10 = very dissatisfied)Do you exercise? What do you do and how often?What specifically would you like to see improvement on in your physical body?Do you currently/or have you practiced yoga? Please explain:Do you meditate?Have you ever done an enema? Would you consider doing one?Do you feel like you are in need of a detox? Please explain:Does your home or environment present any toxins that you are aware of?What is a typical day for you look like for meals? Give examples of your breakfast, lunch and dinner:Do you desire to be fully Plant-based? Please explain:Are you or do you desire to be gluten-free? Please explain:Do you crave sugar, alcohol, coffee, cigarettes or any major addictions?Do you cook? If not, who cooks in your home?Will family/or friends be supportive of your desire to make food/or lifestyle changes?Do you have any troubling relationships or situations happening currently? Please explain:Who do you look up to? List inspiring people in your life:What social media accounts or people inspire you? List below:What is your number 1 struggle or ultimate challenge right now?What are your ultimate health and wellness goals? What does your dream life look like over the next year?The most important thing I should do to improve my health is:How often are you in nature?Do you get sun everyday? If not, how often?On a scale of 1-10, how teachable and willing are you to do whatever it takes to achieve your dreams? (10 = perfect student and willing to do whatever it takes)How did you hear about me?Anything else you would like to share?Submit Share
