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Health Diagnostic Questionnaire
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* Indicates required question
Email
*
Your email
Name
Your answer
email
*
Your answer
Date
*
MM
/
DD
/
YYYY
Health and Wellness Goals
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What are your health and wellness goals? WHY are they important to you?
Your answer
Personal Health and Family History
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What is the most important thing you'd like to share about your health?
Your answer
Please list any supplements or medications you take
*
Your answer
Medical Information
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Do you have any medical diagnosis or conditions ?
History of serious illness, hospitalizations, injuries or surgeries
Your answer
Physical Health Information
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Sleep: How many hours each night? How do you describe the quality of your sleep?
Your answer
How is your energy level most days?
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1 (being very low) to 5 (very high)
1
2
3
4
5
Required
Do you experience any pain, stiffness or swelling on a regular basis? If so, please explain
*
Your answer
Do you have any of the follow concerns? (Check all that apply)
*
Metabolic Health
Blood Sugar Imbalances
Elevated Blood pressure
Elevated Cholesterol
Elevated Triglyceride
None
Other:
Required
Do you have any of the following concerns (check all that apply)?
*
Digestive Health
Bloating
Nausea
Constipation
Stomach pain
Diarrhea
Gas (excessive)
None
Other:
Required
How many bowel movements (on average) do you have per day?
*
Less than 1 " I don't usually have a bowel movement daily"
1-2
3 or more each day
Reproductive Health:
Do you have any of the following concerns (check all that apply)?
*
Irregular Menstrual Cycle
Infertility
Low Libido
None
Other:
Required
Hormonal Health:
Do you have any of the following concerns/conditions (check all that apply)?
*
Thyroid Condition
Toxin Exposure
Signs or Symptoms of Hormonal Imbalance
None
Other:
Required
If you check any boxes above: please explain
Your answer
Immune Health:
Do you have any of the following concerns (check all that apply?
*
Autoimmune conditions/disorders
Low Vitamin D Levels
Frequent illness or infection
Allergies and Sensitivities
None
Other:
Required
If you check yes to any of the above, please explain
Your answer
Brain Health:
Do you have any of the following concerns (check all that apply)?
*
Brain Fog
Difficulty Concentrating
Forgetfulness
None
Other:
Required
Nutritional Information
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What does a typical day of eating look like for you? List a few foods/meals & drinks for breakfast, lunch, dinner and snacks
Your answer
What, if anything, you would like to change about your nutrition?
Your answer
Additional comments or information you'd like to share
Your answer
Have you worked with a health coach previously? If so, how was that experience?
Your answer
How motivated are you to make improvements to your nutrition, health and wellness?
*
I'm thinking about it.
1
2
3
4
5
6
7
8
9
10
I want to start today!
What is the #1 thing keeping you from your goals?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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