Client Health History

Personal Information
Name *
Social Information
Health Information
Food Information
Additional Comments
Women's Health
Medical Information
Personal development and coachability
Please rate yourself on a scale of one to five (1=disagree to 5=strongly agree) on each of the following statements.
I believe I am capable of living the life I truly desire. *
I am open to doing things in new and different ways in order to be successful. *
I am an optimistic person. *
I am completely accountable for the results I produce. *
I am satisfied with my current career. *
I am comfortable and confident in my own body. *
To help us both clarify what health goals or concerns you want to address during your program, please take a few moments to fill in the following and bring it to your first session. Please write three goals for each time period.
Should you become a client, we will meet on the same day, at the same time, every other week. Which days work best for you?