Let’s Help Bring Out Your Best Healthiest You!
Thank you for your interest in working together.
This questionnaire helps me understand where you are, what you’re seeking support with, and how to make our time together as focused and productive as possible. Your responses are confidential and will never be shared.
Please complete this form thoughtfully and honestly. There are no right or wrong answers – this is simply information to guide our session.
I also ask that you keep a food and lifestyle journal for at least 7 days prior to our session, noting foods, beverages, supplements, medications, and anything else you feel may be relevant.
You may copy and paste this form into an email or document and use as much space as you need for your answers.
Basic Information
Name:
Email:
Phone:
Preferred method of contact (phone / video):
Best times to reach you:
Date of birth (optional):
Location / time zone (optional):
What Brings You Here
1. What are the main areas you are seeking support with right now?
(Physical, emotional, lifestyle, spiritual, or a combination)
2. How long have you been experiencing these concerns?
Have they changed or progressed over time?
3. Was there a significant event, period of stress, or life change that you feel may have contributed?
(If so, please describe only what you feel comfortable sharing.)
Current Care & History
4. Are you currently under the care of a medical professional?
If yes, for what concerns?
5. Are you currently taking any prescription medications, supplements, herbs, or health products?
Please list names and approximate length of use.
6. What results have you noticed from what you’ve tried so far?
What has helped, and what hasn’t?
Lifestyle & Patterns
7. How would you describe your current diet and relationship with food?
(There is no judgment here – honesty helps.)
8. How would you describe your energy levels, sleep, stress, and daily rhythms?
9. Are there any patterns you’ve noticed in your symptoms or well-being?
(Time of day, stress, food, seasons, relationships, etc.)
Goals & Readiness
10. Where would you like to be, ideally, in your health and daily life?
11. What do you feel may be standing in the way of getting there?
12. Do you feel ready to make changes to support your well-being at this time?
If yes, what kind of changes feel realistic for you right now?
Additional Information
13. Is there anything else you feel is important for me to know before our session?
Important Acknowledgment
By submitting this form, you acknowledge that:
- Health coaching with Christie Aphrodite is educational and supportive, not medical care
- This does not establish a physician-patient or therapist-client relationship
- No medical diagnosis, treatment, prescriptions, or psychotherapy will be provided
- You are responsible for your own choices and how you apply any information shared
- Sessions are not reimbursable by medical insurance
- You agree to the stated cancellation policy
Your participation indicates understanding and agreement with the above.
When you have completed this, please email me here so I can get you in the schedule! 🙂
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