Your Age

Gender Identification:

The date of my last physical was:

Your BMI

I have a health problem, illness, disease, diagnosis or negative symptoms or concerns

I need more support around healthy living and lifestyle

I struggle with my emotions, mindset and thoughts

I need a health and wellness overhaul and am seeking a complete life transformation

I am not exercising enough, or I am not exercising properly

I am not eating a balanced diet, or I am not clear on what is a healthy nutrition plan for my body and life

I have been diagnosed with anxiety and/or depression or am experiencing anxiety and/or depression

I feel like having new skills to cope with my emotions and thought patterns would benefit me

I feel overwhelmed with stress or have a lot of stressful things in my life right now

I have experienced trauma or traumatic events in the past

My life feels out of balance in multiple areas and or I am going through a big transition in my life

All of my meals are balanced with fresh fruits, vegetables, protein, healthy fats and healthy carbohydrates

I often eat too much or not enough

I DO NOT have a good relationship with food

I DO NOT drink at least 64 ounces of water per day (1/2 gallon)

I DO NOT have a regular self-care practice that includes caring for my mind, body, heart and spirit

How many of the following things are you currently experiencing or how many of these statements are true:

1. I feel confused about how to create a healthy balanced life
2. I have a chronic illness or disease that impacts my life & health
3. I am unaware how to increase my health and wellbeing effectively
4. I do not take consistent actions to increase my health and well-being
5. I usually do not actively seek out additional ways to get more tools, resources & information to live a healthier life
6. I need support from a number of different types of experts to solve my health & wellness problems
7. I need a complete life transformation
8. I often can’t deal with life and feel like staying in bed
9. I feel low energy frequently
10. I know I could be healthier
11. I am at least 10 pounds overweight
12. I have a chronic illness, disease or injury
13. I do not have enough energy
14. My eating habits are poor
15. I struggle with negative emotions
16. I do not have a consistent exercise routine
17. I constantly feel stressed out or out of balance
18. I feel good but know there is always room for improvement
19. I am not happy with my life
20. I experience poor health

How many of the following things are you currently experiencing or how many of these statements are true: When you experience stress, negative feelings and/or emotions, what do you typically do to deal with them? What do you do to avoid feeling uncomfortable? How do you escape or process them ?

1. Overeat
2. Avoid eating
3. Isolate
4. Get angry and explode at people
5. Avoid the conflict
6. Watch TV or movies
7. Surf the internet
8. Shop
9. Drink alcohol
10. Do drugs
11. Avoid my emotions
12. Play video games or online game

My biggest goals are: