Fill out your Wellness Intake Form Here

Name

Address

Address 2:

City

State

Zipcode

Email:

Preferred Contact Phone Number:

How did you hear about me?

Age:

Date of birth:

Height:

Current weight:

Weight one year ago:

Ideal weight:

History of family health problems:

Occupation:

Please rate stress levels on a scale of 1-10 (10 being highest):

How would you rate the pace of your life?

Do you experience any troubles with digestion? (constipation, diarrhea, IBS, colitis, acid reflux, etc.)

How do you sleep at night?

How much water do you drink per day?

Do you eat when you are bored? Stressed?

Do you have challenges with portion control?

Are you addicted to any of the following?

How often do you exercise?

Have you tried health/weight loss/nutrition/wellness programs in the past?

If so, which, and were they successful?

Do you take any Medications/Supplements, if so please list Therapies: (i.e. mental health, massage, or other)?

Please detail the foods you typically eat for Breakfast

For Lunch

For Dinner

Snacks

Beverages

What are your major health concerns?

What would you like to be different 6 months from now?

What is holding you back from being healthier?

Would support with you health and wellness goals be of interest to you?

Do your prefer group or individualized support?

Is there anything else that is important to know regarding your health that you have not mentioned.

Thank you for filling out your Wellness Intake Form!.

If you have any questions in the meantime, please contact us at [email protected].

Thriving Together,

Suzanne Monroe

The International Association of Wellness Professionals
www.iawp-connect.com
888.836.2362

The Wellness Coach Career Kit contains:
  • * The IAWP Course Catalog
  • * The Wellness Coach Career Quiz
  • * The Healthy Lifestyle Wheel
  • * Interactive tools to help you learn what it’s like to be a Wellness Coach

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