Angela Be, BBA, MS Health, CHHC, QRABoard Certified Holistic Health Coach, Nutrition Consultant and Quantum Coherence Practitioner
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If you are a human and are seeing this field, please leave it blank. Please complete the following questions carefully. This information will help us to build a specialized nutritional program, personally designed for you. All information listed will remain confidential between client and health coach. Personal Information Referred by First Name Last Name Gender MaleFemale Date of Birth Age Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code Email Daytime Phone Evening Phone Height Weight Occupation Number of hours worked per week Relationship status Children Allergies or sensitivities What Blood Type (Digestive Chemistry) are you? What is your ancestory? How is the health of your mother? How is the health of your father? At what point in your life did you feel your best? Health Challenge(s) Please rank your current health concerns and rate their severity (on a scale of 1 to 10, 10 being the most severe). Other Information Please tell us any additional information or concerns about your health. Medications Please list any medications you are currently taking and how long you have been taking them (including birth control pills, aspirin, pain medications, etc.). Cravings Do you crave any of the following? SugarCoffeeCigarettes Other cravings/addictions: Smoking Do you currently smoke? YesNo If yes, how much? How long have you smoked? Do you frequently breath second hand smoke from others who are smoking? At workAt HomeNeither Surgeries What surgeries, operations, traumas, car accidents, etc. have you had? Have you ever had full body anesthesia (i.e., to remove tonsils, wisdom teeth, etc.)? YesNo Do you have breast implants? YesNo Do you have any other surgical implants or protheses? YesNo If yes, please explain: Have you had elective surgery (tummy tuck, face-lift, burned off moles, liposuction, laparoscopy, etc)? YesNo If yes, please explain: Do you have any metal or plastic inside your body (such as pins, clamps, plates, etc)? YesNo If yes, please explain: Scars Please describe any scars on you body (major and minor). Do you have pierced ears or other body piercings? YesNo Do you have any tattoos? YesNo Stress Please rate your current stress level (on a scale of 1 to 10, with 10 being the highest stress). What is the main reason(s) for your stress? If over level 5, what step(s) are you taking to reduce stress? Dental Work Please select dental work you have undergone: Silver fillingsComposites (tooth-colored)ExtractionsBridgeworkPartial or full denturesGold crowns or inlaysStainless steel crowns or inlayesPorcelain crowns or inlaysDeGussa porcelain crowns or inlaysVeneersRoot canalsRoot canals with EndoCalPostImplantsTemporariesBracesBleeding gumsSensitive teethBad biteNew cavaties Please indicate how many of the above selected you have had: Have you had any teeth extracted (wisdom teeth, four bicuspid extraction, etc.)? Have you had dental surgery (gum surgery, jaw surgery, etc.)? Do you need further dental work? Please explain: Health Overview For the following questions, please check the phrases that apply to you: Sleep How is your sleep? RestfulRestlessHard to get to sleepWake up oftenGet up during the nightBad dreams Other symptoms: What time do you usually go to sleep? Number of hours of sleep per night: Digestion How is your digestion? AdequatePoorAcid refluxBurp oftenBloatingBurning/Pain in stomach Other symptoms: Urination How are you daily urinations? Every 2 to 3 hoursToo frequentSense of urgencyToo small amountToo large amountBurningDribblingUp at night several times Other symptoms: Bowels How are you bowel eliminations? Frequency: 3 times dailyOnce per daySkip days Amount: NormalToo littleToo large Consistency: NormalToo hardVery softDiarrhea Color: BrownBlackWhitish Other: Lots of mucusLots of gasFoul smell Other symptoms: Women Only Birth control history: Are you pregnant? YesNo Are you breast-feeding? YesNo Do you have monthly periods? YesNo Date of last menstrual period: Are you going through menopause? YesNo Have your periods stopped? YesNoOption 3 Have you had a hysterectomy? YesNoOption 3 If so, when? Menstrual Cycle Are your monthly periods regular (28 day cycles)? YesNoOption 3 Number of days of your menstrual flow: Check any symptom(s) you experience associated with your period: CrampingBloatingFeeling weakMood swingsCravingsHeavy bleedingBack painHeadachesBright red bloodDark clotty blood Other menstrual symptoms: Do you experience yeast infections or urinary tract infections? YesNo Exercise What kind of exercise do you do? How often? For how long at a time? Sunlight Amount of natural sunlight you receive daily outside: Amount of sunlight you receive daily through windows: Hours spent daily under fluorescent light: Eyewear Do you wear contact lenses? YesNo Do you wear glasses? YesNo If yes, how many hours per day? Do your lenses have tints? Option 1Option 2Option 3 Do your lenses have anti-glare coating? YesNo Do your lenses have scratch resistant coating? YesNo Electromagnetic Exposure How many hours do you spend daily with the following devices: Watching TV: Working on a computer: Talking on a phone: Talking on a cellular phone: Wearing a pager: Wearing a headset: Wearing a wrist-watch (with battery): Wearing a hearing aid: Riding in a car/truck/vehicle: Near electrical equipment for long periods of time (such as copy machines, high power lines, computers, etc): When you sleep, is your head within 10 feet of a plug-in clock (such as on a nightstand)? YesNo Personal Care Products Please check which of the following you use: ShampooShaving creamDeodorantToothpasteSoapHair permanentHand/body lotionFacial cleanser/moisturizerHair spray/gelFingernail/toenail polishFace make-up/eye make-upPerfumes/colognePersonal (sexual) lubricantContraceptive jelly/spermacideLaundry soapDish washing liquid/powderTub/tile cleanerGlass cleanerAll purpose cleanerToilet freshenerRoach/ant sprayOther chemical exposure (from yard work, workplace, art, etc) Appliances Please check which one of the following you use: Gas stoveElectric stoveElectric heaterElectric blanketWater bedTurbo blendMicrowave ovenAir purifierWater purifier Please indicate the type of any air purifier/water purifier you use? Cookware What type of cookware do you use? Stainless steelAluminumIronTeflon-coatedGlassTitanium 316 Other cookware: Shower filter What type of shower filter do you use (for chlorine protection)? When was your filter last changed? Pets Do you have pets? YesNo If so, what kind/how many? Are pets allowed in the house? YesNo Are pets allowed on your bed? YesNo What do you feed your pet? Food Choices Please check each type of food that you eat often (once a week or more): Pre-made foods: Canned foodBoxed cerealsFrozen dinnersBottled or frozen juicesTake-out food Red meat (beef, pork, lamb): Commercially grownNaturally raised Chicken: Commercially grownNaturally raised Turkey: Commercially grownNaturally raised Fish: Fresh fishFrozen fishAt a restaurantCanned tuna Fresh vegetables: Commercially grown (store bought)Organically grown (store bought)Organically grown (direct from farmer) Fresh fruit: Commercially grown (store bought)Organically grown (store bought)Organically grown (direct from farmer) Whole grains: Commercially grown (store bought)Organically grown (store bought)Organically grown (direct from farmer) Whole beans: Commercially grown (store bought)Organically grown (store bought)Organically grown (direct from farmer) Eggs/Butter: Commercial eggs (store bought)Naturally grown eggsCommercial butterNatural butter Milk: Commercial milkOrganic pasteurized milkOrganic goats milkGood quality, raw whole milk Cheese: Commercial cheeseOrganic cheese (store bought)Aged cheese Condiments: Commercial salt and/or pepperPink salt (PRL)Artificial sweeteners (Equal, Sweet 'N Low, Coffeemate, etc)Commercial ketchup or mustardCommercial vinegarCommercial olive oilPRL olive oilOther PRL oils Food Habits Eating Out Do you eat at restaurants? YesNo If yes, how often? Where? What type of food do you eat at restaurants? Home Meals Do you prepare meals at home? YesNo If so, how often? What type of food do you prepare? Meal Habits Do you: Skip meals oftenHave irregular eating timesEat food past 7pm MSG Do you avoid food/drink that list "natural flavors" (which means hidden MSG) on the label? Water Do you drink tap water? YesNo If you have a home-water purifier, when was the last cartridge change? What brand of drinking water do you use? Typical Diet Please fill out your typical diet for the last few weeks. Please be as detailed as possible. (For example, instead of writing "chicken", identify what brand and how it was prepared "baked organic chicken". Instead of writing "salad", identify what it was made of, such as "salad made with organic baby green lettuce, commercial cherry tomatoes and PRL olive oil".) PLEASE BE HONEST! Breakfast (Identify typical time eaten): Lunch (Identify typical time eaten): Dinner (Identify typical time eaten): Snacks (Identify typical time eaten): Bedroom/Sleep Considerations Bedding Materials What type of sheets and blankets do you use (i.e., 100% cotton, silk, polyester, ploy-blends, wool, etc)? What type of pillow do you use? Mattress What type of mattress do you sleep on (such as box springs, synthetic, futon, latex, etc)? Head Direction What direction does the top of your head point when you sleep (i.e., south, north, northwest, etc)? Darkness Do you sleep with the curtains drawn tightly (so the room is very dark) or is there considerable light in the room when you sleep? Electronic Appliances Is there a computer, TV or electrical appliance near your bed? If so, how far away? Are any electrical appliances left on in the room when you sleep (such as a TV or computer)? Clock Radio Do you sleep with a clock-radio near your bed (within 1 to 2 feet)? Windows Do you sleep near a window? If yes, what direction does the window face? Alarm Do you sleep with a whole-house alarm turned on (which uses infrared beams/sensors within the house)? EMF Exposure Do you sleep with your head at least 1 foot away from the wall? Previous Treatments Have you ever received acupuncture treatments? If so, how many treatments? For what purpose? Electrical Devices Worn on Body Do you wear a hearing aid? YesNo If yes, which ear(s)? Do you wear a battery-operated watch? YesNo Do you wear a pacemaker? YesNo Do you wear any other electrically-powered device on your body? YesNo If yes, what and where? EMF Exposure Do you use a cell phone? Yes No If yes, how often? Do you live or work within 1/2 mile of a cell phone tower? YesNo Do you live or work within 100 feet or less of a power transformer (on a telephone pole)? YesNo Do you wear a pager? YesNo If yes, how often? Toxic Body Exposure Do you wear fingernail or toenail polish? YesNo Have you ever worn fingernail or toenail polish? YesNo If yes, for how long? Have you ever had toxic chemicals spill on your body? YesNo If yes, what? Vaccinations Have you received the smallpox vaccine? YesNo Have you taken oral polio vaccine? YesNo Personal Health Goals Do you want to lose weight? YesNo If so, how much? How important is your health to you, on a scale from 1 to 10 (1 is the lowest; 10 is the highest)? How much confidence do you have in medical drugs, on a scale from 1 to 10 (1 is the lowest; 10 is the highest)? How much confidence do you have in your body's ability to heal itself (if given the right nutrients/natural therapies), on a scale from 1 to 10 (1 is the lowest; 10 is the highest)? List any nutritional supplements that you regularly take: List any healers, helpers or therapies in which you are involved: What best describes your diet overall? (check all that apply) Mostly eat out (fast food)Mostly eat out (but try to eat healthier items)Eat whatever is availableOccasional bingesWould never give up meatEat a lot of fresh food (very little from cans, boxes)Mostly homemade mealsVegetarianEat mostly organicEat a lot of raw foodIn transition to eating better What are your specific health goals (what do you really want)? In your opinion, what is the most important thing you should do to improve your health? How far are you willing to commit to achieve your health goals? Don't really want to change muchWilling to change someWilling to change a reasonable amountWilling to do whatever it takes How much money do you spend per month on your health, out-of-pocket? How long do you want to live (check all that apply)? Age 60 to 70Age 70 to 80Age 80 to 90Age 90 to 100Age 100+As long as I am healthyAs long as I have been grantedUntil I complete my mission (purpose on earth)Only if my significant other is still alive alsoForeverIt's already enough Anything else you would like to share:
How are you bowel eliminations?