Coaching Client Intake

Bee Well Wellness Health & Wellness Coaching

This is a questionnaire that will make our coaching a little easier!

Question Title

* 1. Can you tell me about yourself?

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Can you tell me about your body?

Height:

Weight:

Ideal Weight:

Weight 1 year ago:

Question Title

* 3. Can you tell me about your health?

What are your main health concerns? (Describe in detail, including the severity of the symptoms):

When did you first experience these concerns?

What other health practitioners are you currently seeing? List name, specialty and phone # below.

. Please list the date and description of any surgical procedures you have had
(including breast reduction or augmentation).

How often have you taken antibiotics as an adult?

List any medicine you are currently taking:

List all vitamins, minerals, herbs and nutritional supplements you are now taking:

Have any other family members had similar problems (describe)?

Question Title

* 4. Can you tell me about your nutritional status?

Are there any foods that you avoid because of the way they make you feel?
If yes, please name the food and the symptom:

Do you have symptoms immediately after eating like bloating, gas, sneezing or hives?
If so, please explain:

Are you aware of any delayed symptoms after eating certain foods such as fatigue, muscle aches,
sinus congestion, etc? If so, please explain?

Are there foods that you crave? If so, please explain:

Describe your diet at the onset of your health concerns:

Do you have any known food allergies or sensitivities?

Question Title

* 5. Which of the following foods do you consume regularly?

Soda

diet soda

refined sugar

alcohol

fast food

gluten

dairy

coffee

Question Title

* 6. Are you currently on a special diet?

autoimmune paleo (AIP)

SCD/GAPS

dairy restricted or dairy-free

vegetarian

vegan

paleo

blood type

raw

refined sugar-free

gluten-free

Other (please specify)

Question Title

* 7. What percentage of your meals are home-cooked?

100

Question Title

* 8. Can you tell me about your lifestyle?

Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time.

Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?

How do you handle stress?

Are you satisfied with your sleep?

Do you stay awake all day without dozing?

Are you asleep (or trying to sleep) between 2:00 a.m. and 4:00 a.m.?

Do you fall asleep in less than 30 minutes?

Do you sleep between 6 and 8 hours per night?

How are your moods in general? Do you experience more anxiety, depression or anger than you
would like?

On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy

At what point in your life did you feel best? Why?

Do you think family and friends will be supportive of you making health and lifestyle changes toimprove your
quality of life? Explain, if no.

Who in you family or on your health care team will be most supportive of you making dietary change?

Please describe any other information you think would be useful in helping to address your health concern(s):

What are your health goals and aspirations?

Though it may seem odd, please consider why you might want to achieve that for yourself: