Section 1 of 8 in this document
Holistic Health Assessment Form
Date
Full Name
First Name
Last Name
Full Address
Street Address
City
State
Zip
Phone Number
Email
Date of birth
Marital Status
Single
Married
Divorced
Separated
Widowed
What is your living situation? Living alone, with family, extended family, roommates, romantic partner live-in, etc...
Do you have any children? If so, how many and ages?
Current occupation
Section 2 of 8 in this document
What would you like to change in your life at this time?.. main reason for this consultation (coaching with Maria)
In ONE word, how do you feel in your life right now?
In ONE word, what do you desire to feel right now?
What do you think is preventing you from feeling this way right now?
In ONE word, what is your desired feeling by the end of our time working together? (could be same word as how you feel right now or different ;-)
Are you familiar with Ayurveda? If so, what is your experience with it?
What behaviors/habits/patterns do feel you engage in that are not supportive to the changes you want?
If we were to work together beyond a consultation, what is your commitment level in making lifestyle/health changes? 1-10, with 10 being solid commitment.
What obstacles may be in the way to bringing you your desired outcome?
Section 3 of 8 in this document
Describe any significant PAST physical or mental health issues and how you overcame them.
Describe your PRESENT health issues, concerns and approximate duration. (physical, mental, emotional)
Do you have any body pain? If so, where?
Are you still menstruating? If yes, are your cycles regular? If no, when was your last moon cycle?
Are you taking any drugs? Legal, not legal. If so, write them here.
Are you taking any herbs regularly? If so, list them here.
Do you have any addictions -- coffee, drugs, black tea, cigarettes, etc...? How long has this been a habit?
Have you experienced any traumatic experiences your life? If yes, discuss briefly.
What do you do for enjoyment, leisure, creativity?
Section 4 of 8 in this document
Work Satisfaction
Love it
Ok/temporary
Unhappy
Family Life
Good
Average
Not good
Not existent (not keeping in touch at all)
Social Life
Good
Average
Not so good
Section 5 of 8 in this document
How would you describe your digestion?
Strong
Weak
Fast
Slow
Bloating
Gas
Describe what you generally eat for breakfast, lunch, dinner, any snacks.
Do you eat between meals? If so, describe.
Do you eat your meals at the same time each day? Give or take 30min.
yes
no
Which is your larger meal of the day?
breakfast
lunch
dinner
How much water do you drink a day?
None
1-2 glasses
3-4 glasses
5-6 glasses
7+ glasses
What's your eating habit like?
I eat with full attention to my meal
Talk a lot while eating
Eat at my desk while working
I eat while stressed
I eat when sad
Eating very quickly
Eat while watching TV
Eat while reading
Rarely eat while sitting down
Describe your diet.
Strict vegetarian
Vegetarian with occasional meat
Vegan
I eat pretty much anything.
Describe any special diet you're on.
How would you describe your bowel movements.
Once a day
2-3 times a day
Once every other day
First thing in the morning
Late in day
Immediately after meal
Need laxatives periodically
Bowel nature
soft
medium
hard
Section 6 of 8 in this document
What time do you usually wake up?
What time do you usually go to sleep?
How often do you exercise? And what forms of exercise do you do?
Do you follow a daily routine? If so, briefly list activities.
How is your energy throughout the day?
I wake up feeling refreshed and ready for day
I'm slow to wake only with caffeine
I get a second wind of energy in the evening
I feel groggy upon waking
I feel exhausted and fatigued at end of day
I feel a crash mid day
Do you have a spiritual practice?
Section 7 of 8 in this document
Do you drink alcohol? If so, how often?
Do you experience any of the following? Choose any that apply.
Depression
Anxiety
Fear or panic
Loneliness
Worry
High Stress
Anger
Lack of memory
Light-headedness
Lack of energy
Lethargy
Suicidal thoughts or attempts
Irritation
How purposeful does your life feel?
Completely
Somewhat
Neutral
Purposeless
Additional comments or concerns that will help guide our time together.
Thank you for taking the time to fill this form out. Talk to you soon.
disregard this