Personal Information Name * First Name Last Name Gender * Male Female Date Of Birth * MM DD YYYY Occupation Email * Phone * Country (###) ### #### Preferred Contact Method Phone Text Email Mail WhatsApp Emergency Contact Information Name * First Name Last Name Phone * Country (###) ### #### Relationship To You * Spouse Sibling Friend Parent Cousin Child Health And Wellness Goals What are your health and wellness goals? Why are they important to you? * What are changes you would like to make in your life over the next 2 years? * What short-term goals would you like to accomplish over the next 3 to 6 months? * What previous steps have you already taken to achieve your goals? What has been the result so far, and what have you learned? * Where do you see yourself 1 year from now? What do you think it will take to get you there? * Personal Health And Family History Health Information What’s the most important thing you’d like to share about your health story? Do you have any of the following? If so, please select all that apply. Primary care provider Other physicians or specialists Practitioners, therapists, healers, etc. Please list any supplements or medications you are currently taking. Have you experienced any barriers or challenges to accessing healthcare? Medical Information Do you have any of the following? If your answer is one of the first two options, please provide a brief description in the box below. Medical diagnoses or conditions History of serious illnesses, hospitalizations, injuries, or surgeries None of the above Family History Describe the health of your father. Describe the health of your mother. Is there anything from your childhood pertaining to your health that you’d like to share? Do you have any other notable family or personal health information you’d like to share? PHYSICAL HEALTH INFORMATION Current Weight: * Height: * How many hours do you sleep per night on average? * How would you describe your quality of sleep? * How is your energy level most days? * 1 being very low - 5 being very high 1 2 3 4 5 Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain: * Do you have any of the following concerns? (Check all that apply.) Metabolic health * Blood Sugar Imbalances Elevated Blood Pressure Elevated Cholesterol Elevated Triglycerides None Digestive health * Bloating Nausea Constipation Stomach Pain Diarrhea Gas None How many bowel movements (on average) do you have per day? * Reproductive health * Infertility Irregular Menstrual Cycle Low Libido None Hormonal health * Thyroid Condition Toxin Exposure Signs or Symptoms of Hormonal Imbalance None Immune health * Autoimmune Conditions Low Vitamin D Level Frequent Illness or Infection Allergies and Sensitivities None Brain health * Brain Fog Difficulty Concentrating Forgetfulness None NUTRITION INFORMATION What foods did you grow up eating? * How would you describe your past relationship or history with food? Do any specific memories about food or eating come to mind? Describe your current relationship with food. Do you have any food allergies or intolerances? If so, please list: * Do any of the following apply to you? (Check all that apply.) * Challenges with Preparing Meals Difficulties Chewing or Swallowing Challenges with Access to Food Poor Appetite None Do you regularly use any of the following? (Check all that apply.) * Alcohol Tobacco Products Other Substances None Do you follow a specific eating approach/practice for personal, health, or religious reasons (e.g., vegan, ketogenic, kosher)? If so, please explain: What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume in the corresponding categories: Breakfast * Lunch * Snacks * Dinner * What, if anything, would you like to change about your nutrition? MENTAL AND EMOTIONAL HEALTH INFORMATION How would you describe your overall mental and emotional health? * How do you like to support your mental health? * How do you cope with stress? * What has been your biggest success thus far, and how did you achieve that? * What are things that you feel are hindering you from success? * What does success look like to you? * Using a 1–5 scale (where 1 = never and 5 = always), rate how often you experience each of the following: Anger, Sadness, Excitement, Stress, Fear, Worry, Joy, Love * Example: Anger 3, Sadness 1, etc. LIFESTYLE INFORMATION What are the important relationships in your life? * Is there anything you’d like to share about your social life? If so, please explain: Who do you live with, if anyone? * How many hours per week do you typically work? * What hobbies or recreational activities do you enjoy? * What role does movement, including sports, exercise, and physical activity, play in your life? * What do you value most in your life right now? I have read and accept Soul Fuel Coaching Privacy Policy * Thank you!