Week 1

Day 5: Lower Body

Valerie Diane

Nutrition & Wellness

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Client Questionnaire

Please fill out the following form to help us understand your physical condition and expectations from health coaching.

First Name

Phone

Email Address

Date of Birth

Last Name

Occupation

Height

Weight

What is the main reason you are seeking nutrition and health coaching?

Have you worked with a nutritionist, health coach, or functional medicine doctor in the past? If yes, explain.

Do you smoke?

Yes

Do you drink alcohol?

Yes

Do you exercise? If yes, how often and what type of exercise do you do?

Check if you have any of the followig medica conditions

High blood pressure

Thyroid Disorder

Joint Replacement

High Cholesterol

Constipation/diarrhea

Indigestion

Brain Fog

Cancer

Chronic Pain/Joint Pain

Visual Deficits

Edema

Stress

Sudden Weight Gain/Loss

Osteoporosis

Diabetes

Neuropathy

Headaches

Other

List any medications or supplements you are taking.

Do you, or have you ever followed a special diet plan (vegan, paleo, gluten free, ect.)?

Who do you live with?

Who does the grocery shopping in your home?

Who does the cooking in your home?

Are there any food you will not eat?

Do you eat late at night?

How well do you sleep?

Do you travel for work?

How often do you eat out?

What are some of your goals in regards to health and wellness?

Has any particular health plan or diet worked or not worked for you in the past?

Please add any additional relevant information here:

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thank You For Submitting!

Email: valerie@embody-wellness.com

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