top of page

Health History Form

I practice a holistic approach to health and wellness, which means that I look at how all areas of your life are connected.

Does stress at your job or in your relationship cause you to overeat? Does lack of sleep or low energy prevent you from exercising?

 

As we work together, we will look at how all parts of your life affect your health as a whole.

​

My approach is not to dwell on calories, carbs, fats, and proteins. It is not to create lists of restrictions or good and bad foods. Instead, I work with my clients to create a happy, healthy life in a way that is flexible, fun and rewarding.

​

Together we’ll work to reach your health goals in areas such as achieving optimal weight, reducing food cravings, increasing sleep, and maximizing energy. As we work together, you’ll develop a deeper understanding of the food and lifestyle choices that work best for you and implement lasting changes that will improve your energy, balance and health.

​

Are you curious about how health coaching can help you? Let’s talk. Fil out the form below to schedule an initial consultation with me. 

Please complete all answers to the best of your ability as it will help me understand where I can support you.

​

This is an in-depth form which many women tell me can be confronting to fill out. Feel free to take your time and know that I have seen and heard it all so don't worry about the answers that you give.

 

Being open and honest is the best way to get the right support for your unique body and situation.

Would you like your weight to be different?
Yes
No
Relationship Status
Single
Married
In a Relationship
Widow
Divorced
It's Complicated
What is your blood type? (if you don't know leave blank)
O+
O-
A-
A+
B-
B+
AB-
AB+
Do you sleep well?
Yes
No
Do you wake up at night?
Yes
No
Sometimes
If you answered yes, why do you wake?
To go to the toilet
Mind is racing
Hot flashes
Nightmares
Children waking me
Other
Any pain, stiffness or swelling?
Yes
No
Are your periods regular?
Yes
No
No longer get a period
Is your period painful or symptomatic?
Yes
No
Have you reached or approaching Menopause?
Yes - reached Menopause
Yes - in Perimenopause
No
Do you follow a strict gluten free diet?
Yes
No
I try to
I need help with this
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Yes
No
Unsure
Do you cook?
Yes
No
If you answered yes, have you tried to give up any of your addictions?
Yes
No

Thank you for completing the Health History form. Someone from Belinda's team will be in touch to schedule a time with you to talk with Belinda so you can decide together if you are a good fit for coaching.

bottom of page