Sahmura Gonzalez
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Cart
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About
Services
Resources
Contact
Sahmura Gonzalez
Integrative Health Coach & Personal Trainer
Integrative Health Coaching Intake Form
General Information
Name
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First Name
Last Name
Date of Birth
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Age
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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Email
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Relationship Status
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Kids
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Pets
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Occupation
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Reason for Seeking Health Coaching
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Emergency Contact
Name of Emergency Contact
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First Name
Last Name
Relationship
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Phone
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Referred By
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Online Search
Website
Facebook
Instagram
Personal Referral
Other
If you selected Personal Referral or Other please share.
Medical and Health History
Height
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Current Weight
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Are you under the care of a physician for any health conditions? If yes, please describe.
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Are you currently taking any medications? If yes, please describe
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Please list and date past serious illnesses/hospitalizations/injuries/surgical history
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Any other health conditions that you aren't seeing your doctor for, but are currently experiencing?
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Ex: Anxiety, TMJ, Constipation/ Irritable Bowel Syndrome, Headaches, Fatigue...
How many hours of sleep do you get per night?
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How is the quality of your sleep? Do you wake up at night? If so, why?
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Laying the Foundation for Coaching
What do want to get from the coaching relationship?
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What is the “best” way for me to coach you most effectively, what tips would you give to me about what would work best?
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Do you have any apprehension or pre-conceived ideas about coaching?
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What else would like to me to know about you?
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Thank you!