Angela Perry, CHHC, MS, QRABoard Certified Holistic Health Coach, Nutrition Consultant and Quantum Coherence Practitioner
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All information listed will remain confidential between child, parent and health coach.
Email or parents' email
Date of Birth
Place of Birth
If applicable, do you enjoy school? Please explain:
Do you have a large or small group of friends?
Who is your best friend?
What do you do for fun?
What is your favorite sport or activity?
What are fun things you do with family?
What are your favorite things to do on your free time?
What chores do you do around the house?
What are your main health concerns/challenges?
When is bedtime?
When do you wake up?
Do you ever wake up at night?
Do you ever have nightmares?
Do you get bellyaches?
Do you get headaches or earaches?
Is it hard to see or read?
Do you get itchy?
Allergies or sensitivities?
Delivery: Vaginal or C-section?
Breastfed or Formula?
Antibiotic or Drug use History?
What do you eat for breakfast?
What do you eat for lunch?
What do you eat for dinner?
What do you eat for snacks?
What do you drink?
What foods do you wish you could eat more often?
What foods do you wish you never had to eat again?
Do you have anything else you would like to share?