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HEALTH COACHING FORM

WELCOME...

Thank you for choosing to work with me. To get things rolling I would be grateful if you could fill in the information asked below. This helps me get a good understanding of your current fitness level, goals, diet and generally a bit about you.

The more information you can supply the better I can make your plan more bespoke for you and in order to create a great skincare plan.

All information given is kept confidential and I request that the information supplied is used solely by you and is not shared.

The consultation is split into three sections; Nutrition Analysis, Physical Training Analysis & Food Diary. Please fill in all sections before submitting. Please answer the questions truthfully and accurately.

There is a goal-setting question for each section. Adding facts and figures to this goal will help you track your progress and evaluate the results. We can also review your goals and provide the relevant and correct advice.

Use the SMART principle when setting goals.

This is;

Specific – What exactly do you want to achieve using this plan? E.g. better skin health

Measurable – What methods can you use to record progress? E.g. Mirror/images

Actionable – What do you believe is required to achieve your goal? E.g. better food choices

Realistic – Can you achieve this goal, even with help? What might hold you back?

Time frame– By when do you want to achieve your goal?

Initial health coaching consultation form

Please fill out the following form to help us understand your physical condition.

Please complete this form a minimum of 48 hours before your online consultation with Emmaline.

Please make payment for the online consultation within 48 hours of making an appointment to confirm your booking.

Any online consultations that have not been paid for within this time frame will not be carried out

Please be aware this consultation is not a replacement for medical advice.

Results can vary from client to client and any opinions are solely my own.

As a health coach I am not permitted to diagnose, or claim to treat, medical conditions.

As a client...

you are responsible for contacting your GP about any health concerns.
You must understand that the advice is personal to you and may not be appropriate for others.
You declare that all the information we share during this professional relationship is confidential and to the best of our knowledge, true and correct.

I confirm everything I have read and agree to the above statements

First Name

Last Name

Date of Birth

Email Address

Occupation

Phone

Do you have any health problems? Are you on any medication or have you been on any in the last 3-6 months?

Do you have any known allergies

Are you currently...

Pregnant

Breastfeeding

Suffering from a hormonal imbalance

Scale Weight

Do you smoke, if so, how many?

Do you consume alcohol, if so, how much?

Height

Where did you hear about me?

How are you feeling right this minute?

How healthy do you currently feel?

Do you have sleeping problems? Do you suffer with stress/tension? Please detail

Please describe your current nutritional knowledge level

NUTRITION ANALYSIS

1. Please describe any previous diets that you have followed, how successful they were and how you felt during them. E.g. Paleo, low carb, weight watchers, intermittent fasting etc.

2. Please describe what your favorite healthy food choices are. Include what your favorite protein; carbohydrate and fat source is E.g. Tuna, Pasta and Eggs.

3. Please highlight any foods you do NOT like:

4. Please describe any allergies and/or intolerances you may have:foods you do NOT like:

5. Are there any other foods to which you’re particularly sensitive (i.e., which cause excessive gas, bloating, stuffiness)?

6. Please describe your current supplements (i.e. protein powder, creatine, vitamins/minerals) intake. If you do not currently take supplements, are you willing to introduce some beneficial ones?

7. What are your current weekly budget requirements for food shopping and supplements?

8. Please describe your goals in relation to a nutrition program. Remember to use the SMART (page 1) principle when setting these.

9. To date, what is the main factor(s) holding you back from achieving your nutrition goals?

10. Please provide a timetable with your most normal daily schedule, listing the time you wake up, work, have breaks, eat, work out and go to sleep:

11. Do you have any weekly activities that you undertake e.g. Football every Tuesday night?

12. Do you currently take any medication?

13. How do you feel after eating a large carbohydrate meal e.g. bowl of pasta?

14. Do you eat meat? If so, do you enjoy eating white or red meats the most?

15. Do you get food cravings, if so, what for?

16. Do you ever binge eat?

17. Would you say you have a good relationship with food?

PHYSICAL ANALYSIS

1. Please describe what current training/sportyou do (if applicable) E.g. Weight Training/Cardiovascular exercise/yoga/pilates

2. Please describe any current or previous injuries you have obtained that may affect your physical training;

3. Please provide details of the type of exercise you normally perform each day with the duration, e.g. Monday - Weights (evening) - 1.5h; Tuesday - Cardio (lunch time) 30m...

4. Please describe your goals in relation to a physical training program. Remember to use the SMART (page 1) principle when setting these;

5. To date, what is the main factor(s) holding you back from achieving your training goals?

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

FOOD DIARY

It is essential to look at your current nutrition in order to maximize the help I can provide you with and to get the correct starting point for your nutrition plan. By looking at your current diet I will be able to see your current nutrition lifestyle and find any problems within it. I can then tailor your new plan to remove these problems while still respecting your lifestyle so we can achieve your results while making the integration process as easy as possible.

Please detail all food, liquids and supplements that you consume for at least the next 3 days. After 3 days of consistently tracking your food please email me the food diary after you have completed the consultation. Please send this email to hello@tsui.life

AND FINALLY...

Thank you for completing the consultation process, this greatly benefits me for creating your plan, getting to know you and provide you with the best advice and support. I hope it has encouraged you to think hard about your goals, were you currently stand in achieving these and how to achieve them. By doing so you have already completed one of the main hurdles that face people when trying to achieve their ideal body health.

Thank you so much

Emmaline

E M M A L I N E T S U I

A METHODICAL APPROACH TO SKIN HEALTH