WELCOME!
Congratulations on your first step to a healthier YOU. Health History. Your answers will remain confidential between you and your Health Coach.
Email *
Hello, what would you like to be called? *
What is the best way to reach you? *
Required
Phone number *
Social Media
Birthdate *
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DD
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Age *
Check most applicable: *
IS HAVING A HEALTH COACH RIGHT FOR YOU?
If you’re not ready, nor willing to contagiously face your fear of change to begin a mental, physical, and/or spiritual transformative journey, bekept accountable, and explore new ideas, I encourage you to rethink investing in a Health Coach at this time. If this is you, please skip to the end of the survey and good luck on your journey. Keep Rooted Within in your thoughts and I’d love to hear from you when you are ready for change.
IN SESSION, YOU WOULD LIKE TO INCORPORATE:
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HOME ENVIRONMENT
Where were you born and where did you grew up?
Where do you currently live? *
You live with:
PHYSICAL
Any pain, stiffness, or swelling?
What is your current weight?
Are you_________with your current weight?
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Would you like your weight to be different?
List ways you provide self-care.
What role does sports and exercise play in your life?
SOCIAL LIFE
Relationship Status:
Children?
Any Four legged, feathered or scaled family members?
Hobbies?
Community involvement/ Volunteer work?
Would your family and/or friends be supportive in lifestyle changes?
CAREER
Occupation:
Hours of work per week: Day or Night Shift
FINANCES
CREATIVITY
Do youself medicate have a repeated behavior to ease pain?
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List any main health concerns:
Any serious illnesses, hospitalizations, injuries? List:
Non Food allergies or sensitivities? Please explain:
How is/ was the health of your biological father?
How is/ was the health of your biological mother?
What is your ancestry?
Other concerns and/or goals?
SLEEP HEALTH
How is your sleep?
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What keeps you up?
What helps you fall asleep?
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Do you wake up at night?
MEDICAL INFORMATION
You’re doing great! Please answer the following:
Do you take any supplements or medications? Please list:

What is your blood type
MENTAL HEALTH
At what point in your life did you feel at your best?
Any healers, helpers, or therapies with which you are involved? Please list:
DAILY YOU:
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FOOD INFORMATION
Your go to treat:
What was your food like as a kid?
Breakfast:
Lunch:
Dinner:
Snacks and liquids:
What is your food like these days?
Breakfast:
Lunch:
Dinner:
Snacks and liquids:
Food allergies or sensitivities?
ANY:
What is the most important thing in your diet that you need to change for the better?
Do you have any major cravings? Example: sugar, caffeine, nicotine…
What percentage of your meals are home cooked?
Where does the other food come from?
Any food restrictions? For how long?
Are you ready to take responsibility for your actions, acknowledge feelings, and be challenged with change? *
DISCLAIMERS, HEALTHCARE RELATED CLAIMS, CONFIDENTIALITY, ARBITRATION, CHOICE OF LAW, AND LIMITED REMEDIES
DISCLAIMERS
The Client understands that the role of the Health Coach, Madison Garcia Villalon is not to prescribe or assess micro- and macronutrient levels; provide health care, medical or nutrition therapy services; or to diagnose, treat or cure any disease, condition or other physical or mental ailment of the human body. Rather, the Coach,  Madison Garcia Villalon is a mentor and guide who has been trained in holistic health coaching to help clients reach their own health goals by helping clients devise and implement positive, sustainable lifestyle changes. The Client understands that the Coach, Madison Garcia Villalon is not acting in the capacity of a doctor, licensed dietician-nutritionist, psychologist or other licensed or registered professional, and that any advice given by the Coach,  Madison Garcia Villalon is not meant to take the place of advice by these professionals. If the Client is under the care of a health care professional or currently uses prescription medications, the Client should discuss any dietary changes or potential dietary supplements use with his or her doctor and should not discontinue any prescription medications without first consulting his or her doctor.  
The Client has chosen to work with the Coach, Madison Garcia Villalon and understands that the information received should not be seen as medical or nursing advice and is not meant to take the place of seeing licensed health professionals.
The Coach reserves the right to cancel the program if at any point she or he feels it is not advantageous for the coaching program to continue. If this happens, the Client is only responsible for the pro rata share of coaching services received.

 PERSONAL RESPONSIBILITY AND RELEASE OF HEALTH CARE RELATED CLAIMS
The Client acknowledges that the Client takes full responsibility for the Client’s life and well-being, as well as the lives and well-being of the Client’s family and children (where applicable), and all decisions made during and after this program.  
The Client expressly assumes the risks of the Program, including the risks of trying new foods or supplements, and the risks inherent in making lifestyle changes. The Client releases the Coach, Madison Garcia Villalon from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the Client ever had, now has or will have in the future against the Coach, Madison Garcia Villalon arising from the Client’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the Coach, Madison Garcia Villalon.
 
CONFIDENTIALITY
The Coach, Madison Garcia Villalon will keep the Client’s information private, and will not share the Client’s information to any third party unless compelled to by law.
 
ARBITRATION, CHOICE OF LAW, AND LIMITED REMEDIES
In the event that there ever arises a dispute between Coach, Madison Garcia Villalon and Client with respect to the services provided pursuant to this agreement or otherwise pertaining to the relationship between the parties, the parties agree to submit to binding arbitration before the American Arbitration Association (Commercial Arbitration and Mediation Center for the Americas Mediation and Arbitration Rules). Any judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Such arbitration shall be conducted by a single arbitrator. The sole remedy that can be awarded to the Client in the event that an award is granted in arbitration is refund of the Program Fee. Without limiting the generality of the foregoing, no award of consequential or other damages, unless specifically set forth herein, may be granted to the Client.
This agreement shall be construed according to the laws of the State of Wisconsin. In the event that any provision of this Agreement is deemed unenforceable, the remaining portions of the Agreement shall be severed and remain in full force.  
If the terms of this Agreement are acceptable, please sign the acceptance below. By doing so, the Client acknowledges that: (1) he/she has received a copy of this letter agreement; (2) he/she has had an opportunity to discuss the contents with the Coach, Madison Garcia Villalon and, if desired, to have it reviewed by an attorney; and (3) the client understands, accepts and agrees to abide by the terms hereof.
YOU HAVE READ AND AGREE WITH TERMS ABOVE: WRITE OUT FULL NAME *
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