STEP 1: Consultation Request Form

Pure Lifestyle Wellness
Where FAITH, FITNESS and NUTRITION Collide!

Please complete this questionnaire prior to your initial consultation. The information provided will help me determine how I can best support you in reaching your goals. Please take your time to answer each question with intention. Your transparency and full disclosure will ensure I provide you with the best service possible. Your privacy is my top priority!

PART 1: PERSONAL INFORMATION

First Name *
Last Name *
Email address *
Phone *
Date of Birth *
Gender *
Height *
Weight *

PART 2: PERSONAL HEALTH HISTORY

Are you currently under the care of a medical provider? *
If your answer is YES please specify.
Please list all past and present medical diagnosis.
Please list any past or present injuries.
Please list all supplements you are currently taking, including vitamins, herbs, and minerals.
Please list all prescription medications you are currently taking.

PART 3: PHYSICAL FITNESS

How often do you exercise? *
Have you been advised by a doctor to avoid physical activity? *
What are some physical activities that you enjoy?
Describe your feelings and thoughts about your relationship with exercise.

PART 4: NUTRITION

Please tell me about your current nutrition habits.
Do you experience digestive difficulties?
How many bowel movements do you have each day?
Within the past year, have you been tested for food intolerances or allergies?
Please list any known food intolerances.
Do you avoid these foods?
If you have not already been tested, would you be open to being tested?
Please specify how much water you drink daily.
Do you consume coffee regularly?
Do you consume tea regularly?
Do you consume alcohol regularly?
Please list any other drinks that you consume on a regular basis.
How many servings of vegetables do you eat per day?
Please list some of your favorite foods.
Please list some of the foods that you dislike.
Who primarily does the grocery shopping for the household?
Who primarily does the cooking at home?

PART 5: LIFESTYLE

Do you smoke?
How many hours of sleep do you get each night?
Do you have a consistent bed/wake time?
Do you have trouble falling asleep?
Do you have trouble staying asleep?
Do you wake up feeling rested?
Do you have children living at home? If so, how many & what are their ages?
Do you have pets?
What level of stress are you currently experiencing?
Please list your main stressors.
What do you do to relax or relieve your stress?
How many hours per day do you use a computer?
How many hours per day are you on a cell phone?
How many hours per day do you watch tv?
Do you pray daily or participate in a daily devotional?

PART 6: GOALS

Please tell me about your physical goals for the next 6 months. Why are these important to you?
Please tell me about your nutrition goals for the next 6 months. Why are these important to you?
Once you achieve your goals, how will life change, how will you feel? Explain how you will look when you are in a place that you’re happy in your body.
Why do you believe you haven't been able to achieve your goals yet? Tell me what you believe is a roadblock to your long term success.
What have you tried in the past that did not work? Tell me the aspects that were particularly difficult/unappealing
What have you tried in the past that worked well for you? Share what you specifically enjoyed about it and were the most impactful on your results.
From your perspective, how do you feel I can best support you?
How WILLING are you to change behaviors and habits that keep you from your goals?
How ABLE are you to change behaviors and habits that keep you from your goals?

PART 8: CONCLUSION

On a scale of 1-10, how committed are you to making a change to improve your overall well- being (mind, body & soul)?
Is there anything else you think is important for me to know about you or your circumstance before our consultation?

To BOOK the appointment please submit and wait for the calendar to popup

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