Health Coaching Intake

Intake form

Your health and wellbeing can be affected by a number of different factors.  To figure out why you are experiencing the symptoms you are, your health coach will ask you a number of questions to understand your nutrition, stress factors, lifestyle habits, toxic exposure, exercise routines, steep cycles and more.  The information you give provides valuable clues so your health coach can put together a successful personalised wellness plan that will get you results.  As your health coach, I look forward to being your guide on your journey to health and vitality.  Please fill out the form below and we will contact you for an appointment.

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Health Coaching Intake Form
First name
Last name
Postal Code
Email address
Phone NumberBest phone contact
Skype NameFor video consults
Birth date
Place of birth
Referred by
Describe Problem(s)
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What treatments have you tried
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Has anything been successfulIf so what treatment
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With whom do you live
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Do you have any pets or farm animals?If yes where do they live?
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Have you lived or traveled outside of AustraliaIf so when and where?
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Have you or your family recently experienced any major life changes?If so please comment
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Have you experienced any major losses in life?If so please comment
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How much time have you lost from work or school in the past year?
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Previous jobs
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Did you feel safe growing up
Have you been involved in abusive relationships in your life?
Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships?
Do you feel safe, respected and valued in your current relationship?
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse?
Would you prefer not to speak of these issues
List past medical historyincluding surgery
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List previous hospitalisations
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How often have you taken antibiotics
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How often have you taken oral steroids
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What medications are you taking now?Please list
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What vitamins, minerals, supplements & other nutritional supplements are you taking?Please list
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Were you a full term or premature baby? Breast or bottle fed?
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As a child did you eat a lot of sugar and/or candy
What is your typical daily diet
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How much of the following do you consume each week?
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Other caffeine
Candy/ Chocolate
Are you on a special diet?If so what?
Is there anything special about your diet that we should know?
Do you have symptoms immediately after eating, such as belching, bloating,sneezing, hives, etc. If yes are these symptoms associated with any particular food or supplement(s)
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Do you feel much worse when you eat certain food?If so which foods
Do you feel much better when you eat certain foods?If so what foods
Does skipping a meal greatly affect your symptoms?
Have you ever had a food that you craved or really "binged" on over a period of time?
Do you have an aversion to certain foods?If yes what foods
How many Bowel movements do you have per day
Do you have any constipation (straining or less than 1 bowel movement per day) or diarrhoea(loose stool)
Do you have intestinal gas?If so when?
How many times a week do you drink alcohol?
Have you ever used recreational drugs
Have you ever used tobaccoIf so for how long?
Are you exposed to secondary smoke often?
Do you have mercury amalgam fillings in your teeth?If so how many
Do you have any artificial joints or implants?If so which ones?
Do you feel worse at certain times of the yearIf so please specify
Have you, or to your knowledge been exposed to toxic metals in your job or at home?
Do odors affect you?If so which ones?
How would you rate your current level of stress
Have you ever had psychotherapy or counselling?
Are you currently or have you ever been married?
List your hobbies and leisure activities
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Do you exercise regularlyIf so how many times a week
What type of exercise?
Do your parents or siblings have (or had) any health issues? If so, please explain
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Why do you believe you would be a good candidate to work with Shelley VanBarneveld
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