Transformative Life Choices

Name *

First

Last

Phone number

Email *

Date

Age

Sex

Male
Female

Marital status

Do you have a personal relationship with Jesus?

Yes
No

If you anwered “yes” above, please tell me how you incorporate your faith in your life.

If we work together, are you willing to follow the recommended biblical prayer and Christian faith-based strategies?

Yes
No

Please describe your general health status and any diagnoses you currently have.

Please describe how your current state of health impacts your life, relationships, and/or your ability to fulfill your divine purpose for the Lord.

Please list all medications and supplements that you are currently taking and what they are for.

Do you feel like the above-listed medications and supplements are helping?

Yes
No
Not sure

Please list any negative side effects that you feel like you are experiencing from the medications and supplements that you are currently taking.

Have you experienced any kind of trauma at any time in your life, such as medical, physical, emotional, bullying, or abuse of any kind?

Yes
No

If you answered “yes” above, please explain as much as you are comfortable sharing right now.

Please explain a little of your family history (parents & siblings) — medical & mental health, trauma, life-changing events, etc.

Please list THREE areas of concern that you would like to focus on first. This can be adjusted as we move forward.

How would you describe your relationship with your immediate family members?

Do you have any unhealthy relationships with family members or friends?

Yes
No

What did your diet consist of as a child?

My childhood meals were primarily:

Cooked from scratch
Processed, canned, or prepackaged foods
Fast food
Homestyle cooked food from a restaurant

What does your diet consist of now?

My meals now are primarily:

Cooked from scratch
Processed, canned, or prepackaged foods
Fast food
Homestyle cooked food from a restaurant

Do you use any products on your body or hair that contain synthetic frangrances and chemicals?

Yes
No

Do you use any household cleaning or laundry products that contain synthetic fragrances or chemicals?

Yes
No

What interests and activities did you enjoy as a child?

What interests and activities do you enjoy now?

How often do you exercise and what kind of exercise do you do?

What are your gifts and strengths?

What is your current occupation?

How do you feel about your current job? Check all that apply.

Do you want to share anything else about your job and how it impacts your life and health - mentally, physically, and/or spiritually?

What are you so passionate about that if money wasn't an issue, you'd do for free?

Are you satisfied with your current weight? *Please note that we will not focus primarily on weight because as your body is detoxed and your systems are in better balance, excess weight will begin to shed naturally. I just want to get a feel for where you are and how you feel about it right now.

Yes
No
Would like to gain some weight
Would like to lose some weight

My current weight is:

My height is:

If you’ve experienced unwanted weight gain or weight loss, what was going on in your life during that time?

Do you consider yourself to be an emotional eater?

Yes
No

Do you experience depression, anxiety, or panic attacks?

Yes
No

If you answered “yes” above, when did this begin for you, and was anything significant going on in your life then?

If you experience anxiety, panic attacks, depression, etc., what are your current coping strategies and how effective are they?

How do you see yourself right now?

How do you feel about starting a wellness program?

Have you ever worked with a health or life coach before?

Yes
No

If you answered "yes" above, what was your experience?

Are you ready and willing to make necessary changes to improve your health and wellbeing?

Yes
No

What is your desired outcome from a wellness program?

Would you like to schedule a free 30 minute consultation to learn more about my program?

Yes
No
Maybe at a later date

If you answered "yes" above, please select the day and time brackets that work best for you.