Coaching Questionnaire

Please copy this page and paste it in a reply to our most recent email thread. Fill in your answers and return to me at least 48 hours before your next appointment. Thank you!

The Basics

Name:

Age:

Email:

Skype:

Alongside ongoing work. what do you want to work on specifically right now?

Are there any conditions that you are being treated for since your last appointment? Please outline any medication or treatment:

Please score how you have felt in the following areas over the last two to three days. Note that the scale is different for each area! Choose just a single number score for each area but feel free to add any extra details. These scores are partly to focus yourself on what has been going on for you lately, and partly to act as a prompt sheet for me so that we don’t miss any relevant health changes or concerns in your appointment.

Energy

No Energy   =   0 – 15   =   High Energy

Your energy score:

Details:

Sleep

Poor Sleep   =  0 – 10   =  Deep, refreshing sleep

Your sleep score:

Details:

Mood

Mostly angry or sad = 0 – 15 = Mostly happy and connected

Your mood score:

Details:

Skin

Dull, dry or spotty; eczema or psoriasis = 0 – 10 = Clear, supple skin

Your skin score:

Details:

Headaches

Frequent, severe, lasting or migraines  = 0 – 10 = None or very rare headaches

Your headache score:

Details:

Digestion

Heartburn, constipation, diarrhoea, cramps = 0 – 15 = Smooth, efficient

Your digestion score:

Details:

Stress

Unable to cope with external stress = 0 – 10 = Easily deal with stressful situations

Your stress score:

Details:

Sinuses

Frequent pain or dripping nose = 0 – 5 = No sinus issues

Your sinus score:

Details:

Physical pain

High and/or constant level = 0 – 10 = no current pain other than a recent accident

Your pain score:

Details:

Add your individual scores up to get your total score _____/100

For women

Please tell me here if there is anything you wish to tell me about your previous cycles:

Please tell me if there is anything you wish to tell me about current perimenopausal or menopausal symptoms:

Since your last appointment

Have any new concerns appeared?

Have any existing concerns been resolved?

Are there any of my last recommendations that you have found difficult? Can you tell me why?

Are there any of my last recommendations that you have found particularly helpful?

Food and Drink Diary

Please also provide me with a recent and detailed three day food and drink diary.

It is useful for me to know details such as how much water you drank each day, whether food is organic, whether it is homemade, what kind of oils or fats you used, how much sugar you took in a drink, whether your meal or snack left you tired, overstuffed or still hungry; and whether you ate from hunger, habit, boredom craving or other emotion.

Include any supplements you currently take: