Whole Woman Wellness Transformation^™

1Please list any past or present medical conditions or diagnoses:

2Are you currently taking any medications? If yes, please list:

3Have you had any surgeries or major medical procedures? If yes, please provide details:

4Do you have any known allergies? If yes, please specify:

5Have you ever been diagnosed with any mental health conditions? If yes, please provide details:

1How would you describe your current level of physical activity?

2Do you smoke? If yes, how many cigarettes per day?

3How many alcoholic beverages do you consume per week?

4How many hours of sleep do you typically get per night?

1How would you describe your typical diet? (e.g., low carb, vegetarian, high protein)

2Do you have any specific dietary restrictions or preferences? If yes, please specify:

3How often do you eat out or order takeout per week?

4Are you currently following any specific diet plan? If yes, please provide details:

1What are your main health goals that you would like to achieve with the help of a health coach?

2On a scale of 1–10, how motivated are you to change your lifestyle and habits to achieve these goals? (1 = not at all motivated, 10 = extremely motivated)

3Do you anticipate any specific challenges or obstacles while working towards your health goals?

4Have you previously worked with a health coach or in any wellness programs? If yes, please provide details:

5Have you ever been diagnosed with any mental health conditions? If yes, please provide details:

Would you like to share any other information that might be relevant to your health coaching journey?