Tell me your health story:

We all come with stories and journeys related to our health and body. Please take a moment to share your personal experiences thus far, so I can better prepare to meet with you one-on-one in a free 50-minute consultation.

Every question on this form is required for submission, but If you do not feel comfortable answering, just write so. I know this process can be intimidating, but I want to assure you that my coaching practice is a judgement-free zone. All the information you share here (and in sessions) will remain confidential--just between us!

This form will take you about 15 minutes to fill out, but I promise they’ll be 15 minutes well spent.

I'm excited to get to know you better! xo Robin

Name:

First Name

Last Name

Email:

PERSONAL

Birthdate (mm/dd/yyyy):

Height:

Current weight:

Weight six months ago:

Weight one year ago:

Would you like your weight to be different? If so, how?

Occupation:

Where do you currently live?

Relationship status:

Children?

Pets?

HEALTH & LIFESTYLE

Please list your main health concerns:

Other concerns and/or goals?

At which point in your life did you feel best?

Any serious illnesses/hospitalisations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

How is your sleep?

How many hours of sleep do you typically get?

Do you wake up at night? If so, why?

Any pain, stiffness, or swelling?

Constipation/diarrhoea/gas/indigestion?

Allergies or sensitivities? Please explain:

Do you take any supplements or medications? Please list:

Any therapies or other health programs with which you are involved?

What role does physical activity play in your life?

NUTRITION

Which foods did you often eat as a child? (breakfast, lunch, dinner, snacks, liquids)

Which foods do you often eat now? (breakfast, lunch, dinner, snacks, liquids)

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?

Do you cook?

What percentage of your food is home-cooked?

Where do you get non-home-cooked food from?

Do you strongly crave sugar, coffee, cigarettes, or have any major addictions?

"The most important thing I should change about my diet to improve my health is...."

ADDITIONAL THOUGHTS

Please add any other thoughts or information you'd like to share:

Your favourite body sense:

* Fun fact-- did you know we are thought to have 7 senses? Vestibular sensing is our body's ability to balance with gravity, and proprioception is our ability to feel where our body parts are in relation to one another. :) YAY science!

Smelling

Seeing

Tasting

Hearing

Feeling

Other