Pre-Planning Form

CONGRATULATIONS on taking the first step toward achieving optimum health and wellness! Together, we'll work on setting sustainable goals using mindset, movement, nutrition, education, strength, stretch, balance, writing, discussion, essential oils, and more. Action, accountability, and achievement are at the core of our approach. I support your health plan with guidance, encouragement, weekly assignments, reminders, and help you track your results.

It's important to note that most of the program occurs outside of our sessions – in your everyday life – so the results are in your hands. WHOLE health goes beyond just diet and exercise. We focus on 12 pillars of health: finances, creativity, career, physical health, mental health, joy, nutrition, social life, spirituality, education, home environment, and relationships. Please consider this as you fill out the information below.

* Skip any questions that are not applicable to you.

Name

First Name

Last Name

Phone

(###)

###

####

What is your preferred communication?

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you ready to do the personal work it takes to make real change?

Do you have the time to dedicate to the program?

Birthday + Birth Place

What is your stress level?

Age + Height + Weight

Please list any health concerns.

List your overall health goals.

At what point in your life did you feel best?

How is/was the health of your mother?

How is/was the health of your father?

Describe your sleep? Do you wake up at night? How many hours do you sleep? Do you have a hard time falling asleep?

Do you currently have a consistent exercise routine?

List any any supplements or medications you take regularly:

List your top 3 favorite forms of exercise or ways to move your body:

List your top 3 favorite forms of self care:

What is your current relationship with food? List your positive eating habits and your not so positive eating habits or mindset around food.

The most important action I can take to improve my health is:

Date

YYYY

Signature

I prioritize my personal health and wellness. I embrace new ideas, tools, and workouts. I value the significance of consuming nourishing foods and engaging in regular exercise. I am prepared to handle life's stressors and willing to put in the effort to honor the commitments I make to myself.