health and history form

Your Information

Your full name:

Name you like to be called

Address:

City:

Province:

Postal Code:

Contact Information

Phone:

E-mail:

Fax:

Employment Information

Company

Occupation

Personal Information

Your age

Marital status

Number of children

Significant other’s (S O’s ) name

S O’s age

How would you rate yourself from 1(low) – 10 (high) on the wheel of lifestyle:

Health & Fitness

Management of Stress

Nutritional Habits with food

Nutritional Habits with beverages i.e. pop, alcohol intake

Awareness of Quality of Air/Water/Soils you take in

Support from Family i.e. spouse, partner, children

Support from Friendships, co-workers

Consistent activities that feed the soul i.e. Meditation, Yoga

Commitment to Self in arena of healthy lifestyle

Commitment to your own personal growth

Consistent patterns of movement and exercise

Living your life on purpose and with joy

Which segment(s) of your lifestyle would you like to focus on currently?

Is there a particular issue that you feel is holding you back from living your lifestyle 100% on track?

How well are you managing the current health you have?

Are there specific lifestyle goals you would like to work towards?

How effectively have you implemented strategies for healthy living in the past?

What results are you looking for from coaching?

What else do I need to know to coach you effectively?

Contact me by

E-mail Phone

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