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Fill out questionnaire and receive a complimentary evaluation.

Name
First Last
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
What is the reason you are seeking holistic health guidance? What role do you see holistic health playing in your current health care practices?
What are your current complaints regarding your health? Where do you see the biggest areas of improvement? Please rank these items from the most important to the least important.
What medications do you currently take? I will need name and dosage and please add if you are compliant in taking the medication as recommended. What traditional and non-traditional medical treatments are you using or have you used?
What is your pertinent medical history? Medical diagnosis, chronic problems, family history, current treatments, etc. Please list any food or medical allergies or medical conditions such as but not limited to: heart disease, diabetes, irritable bowl, leaky gut, bacterial imbalances (yeast etc), acid reflux, diverticulitis etc.
Please list current level of exercise. Please be specific- duration, frequency, intensity and consistency. Are you interested in fitness classes? What kind of classes? Have you ever taken classes or had a trainer work with you? As far a fitness level and conditioning would you rank yourself a beginner, intermediate, or advanced? Do you belong to a gym or fitness group? Would you workout outside?
Please list current caffeine and alcohol intake, drug use, vitamin and supplement usage and over the counter medications you take. Do you smoke? Please list amount and frequency. As specific as possible please.
Please describe your eating habits in a typical workday and a typical day off. List when you eat, if you have a schedule and what kind of foods you regularly eat. Do you cook your own food? Where do you buy your food (grocery, restaurant, fast food)? What foods are commonly consumed? What fried, bagged, prepackaged foods, frozen foods do you eat? What is your amount of consumption of soda, juices, water, milk and sweets? Do you use diet and sugar alternatives?
This is where we will find areas to improve, this is what I enjoy assessing. The more specific you are the better I can assess. I also recommend keeping a journal and taking pictures of labels, ingredients, and amount consumed.
Are you interested in food modification (eating for health, eating nutritious foods, free of preservatives and added chemicals)? Do you believe eating organic is important? Do you believe food impacts your health? If so how much knowledge do you think you have on choosing nutritious foods (none, some or expert)? Do you currently subscribe to any food modifications? Such as eating organic? Vegetarian? Special diet? Do you eat all meats, cheese, eggs and dairy? What are your favorite foods, fruits and veggies? What are your disliked foods, fruits, and veggies?
How do you rank your stress level? 1 being low and 10 being high. What are your top stressors? How do you relieve your stress?
What kind of environment did you grow up in (city, suburb, country)? Are you comfortable in nature? Are you comfortable in a city? How much time do you spend outdoors? How much time driving? How much time sitting at a computer? How much time in front of a TV?
How much do you sleep? Do you sleep the whole night through? Do you have a set sleeping schedule? Do you feel rested after you sleep? Do you feel as though you have any sleep issues? If so, please list them.
How is your family life? How is your social life? Do you feel as though you have a good support system (people you can trust and count on, people you can share your thoughts, fears, concerns with)? Please rank your support system with 1 being no support and 10 being an extensive network of support.
How is your work life? Is it stable? Is it a point of stress in your life? If so, why? Are your boss, your coworkers, and your work environment amicable? Is there another job or work situation you would rather have?
Are you interested in meditation? If so, are you interested in eastern philosophy or would you rather stick to mindfulness training which doesn’t incorporate spirituality? Have you ever or do you currently meditate or practice mindfulness?
*Explanation: Meditation and mindfulness are a type of mind exercise that allows you to train and strengthen your mind and bring it back under control so that you can focus your attention on one thing fully. At any given time the mind is wandering where ever it wants. It is like a one year old, grabbing for anything in sight. There are a lot of benefits (mentally and even physically) in this training if you are interested please ask about it. We can try one complimentary session so you can determine if it is something you enjoy and feel that you benefit from. If you are not interested just note that and we will leave it out of your action plan.

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Questionnaire

Questionnaire

Fill out questionnaire and receive a complimentary evaluation.

Receive my latest newsletter straight to your inbox.

FOLLOW US