Request a Complimentary Assessment Interview

General Information

Date:
Name:
Age:
Birthdate:
Home Phone:
Work Phone:
Cell Phone:
Fax:
Email:
Address:
Occupation:
Height:
Weight:
Since:
Feel best at:
When were you:
Wrist Measurement:	(where your hand meets your arm, just above the wrist bone)
Live:	Alone Partner Spouse Children Pets Other

Children, Names, and Ages:

Medical History and General Health

Please list any major health problems or concerns, including operations:

Year	Problem

Do you smoke?
If so, how long?
How much?

Food Allergies/Sensitivities

Please check below any that apply:

Alcohol
Bananas
Caffeine
Chocolate
Cigarette Smoke
Citrus
Corn
Dairy
Eggplant
Eggs
Gluten
Household Chemicals
Peanuts
Peppers
Shellfish
Soy
Strawberries
Sugars
Sulfites
Theobromaine
Tomatoes
Wheat
Wine
Other:

Organs/Systems Needing Support

Please check below any that apply:

Adrenals
Bones (CNS)
Brain/Nerves
Female Reproductive Organs
Gall Bladder
Gums/Teeth
Hair/Scalp
Hearing (Ears)
Nails
Pancreas
Pituitary
Prostate
Spleen
Thymus
Thyroid
Vision (Eyes)
Other:

What is Your Blood Type?

Current State of Emotions and Well-Being

Please rate each statement below as it relates to you, on a scale of 0-10: 0=never, 10=always:

	It is difficult for me to express my emotions.
	I am often dissatisfied with my mood, attitude, or performance.
	I am often stressed out and feel overwhelmed.
	Even though I'm in a relationship, I often feel lonely.
	I often feel anxious and nervous for no good reason.
	I don't sleep well at night.
	I have a hard time waking up in the morning.
	I often suffer from bad dreams.
	I often have very low energy and feel exhausted mentally and/or physically.
	My family is a source of conflict.
	I don't have enough time or energy for hobbies or recreation I enjoy.
	I often feel depressed, sad, or apathetic for no reason.
	I often become irritated or angry with others.
	I have a hard time letting go of the past.
	I don't have much enthusiasm for the future.
	I am not able to concentrate for extended periods of time.
	My outlook is more negative than positive.
	I worry what other people think of me.
	I tend to see the good in people.
	I have a great sense of humor and love a good joke.
	I receive great joy from my family.
	My outlook on life is generally positive.
	My job uses all my best talents.
	I have plenty of energy to do all the things I want.
	I sleep well at night.
	I feel rested when I wake up.
	I am able to express anger constructively.
	I easily concentrate on tasks at hand, and for as long as it takes.
	I have strong faith in a Higher Power that I can call on.
	I practice meditation or other relaxation techniques.
	I have many close friends that I can count on.
	I accept full responsibility for my actions and what happens to me in kind.
	I trust my intuition.
	I do not harbor any resentment from the past.
	I can feel completely fulfilled even if I'm alone.
	I have hobbies or interests that I enjoy as recreation.
	How I see myself is more important than how others see me.

Personal Support and Motivation

Please list any health care providers, chiropractor, or other consultants you are working with:

Please list any current: 1) medications 2) dosage 3) what they are for:

Please list any current supplements:

Please describe current exercise you perform and how often per week:

What is your intention for this Interview?

Do you feel now is the time for a permanent lifestyle change, and if so, why?

On a scale of 1-10, how important is it to you to be free of what concerns you?

On a scale of 1-10, how committed are you to do what it takes?

What is your biggest challenge?

What do you most want to achieve?

What would be different if you did that?

Anything else I should know about you?

Eating Habits

Describe below your typical meals and beverages. Please be as specific as possible, and include the times you usually eat. For example, instead of "oil" note the type of oil, such as extra virgin olive oil, corn oil, etc. Instead of "bread" list white, whole grain, wheat free, etc. Instead of "vegetables" list the type of vegetable, and whether it is organic, locally grown, eaten raw, fresh, frozen, or canned. Please include all beverages, type and amounts.

Breakfast

Time I usually eat:

Morning Snack(s)

Time I usually eat:

Lunch

Time I usually eat:

Afternoon Snack(s)

Time I usually eat:

Dinner

Time I usually eat:

Evening Snack(s)

Time I usually eat:

DISCLAIMER STATEMENT

Well-Being Coaching, including the use of Metabolic Typing ™, EFT (Emotional Freedom Technique), and any other technologies performed by Sharon “Sheri” Cooke, is solely for the purpose of education and ongoing personal support in reaching your lifestyle goals. Well-Being Coaching is not intended as the diagnosis of, or as treatment for disease. Nor is Well-Being Coaching intended as a substitute for the advice and/or care of a physician, and/or therapist, or meant to discourage or dissuade you from the advice of your physician, an/or therapist. You should regularly consult with a physician and/or therapist in matters relating to your health, and especially with regard to symptoms that may require diagnosis. Any eating or lifestyle regimen should be undertaken under the direct supervision of your physician, and/or therapist. Moreover, if you have chronic or serious ailments, and/or when you make changes to your personal eating or lifestyle regimen, you should be under the direction supervision of your physician, and/or therapist. If you have any unusual medical or nutritional needs or constraints that may conflict with the education and methods received during in-person or telephone coaching sessions with Sharon “Sheri” Cooke, you should consult your physician, and/or therapist. You should not stop or alter any prescribed medications without the advice and guidance of your personal physician, and/or therapist. If you are pregnant or nursing, you should consult your physician before embarking on any nutritional or lifestyle program. I have read and understand the above. I am aware that any information and/or methods I accept and apply to my life received from coaching sessions with Sharon “Sheri” Cooke, I choose to do so freely and with full responsibility, and I hold Sharon “Sheri” Cooke as blameless for my choice, along with results from doing so.

Name:

Date: