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Health Form

Please tell me about yourself. What gets you up in the morning? How do you spend most of your time? How are your relationships – do you have a significant other, kids, etc.? Do you have any pets? What do you do for work?

Why do you want to work with Amanda? What attracted you to her programs?

Tell me about your health. What’s going on right now, and what are your biggest health challenges?

At what point in your life did you feel the best? What were you doing at this time that was different?

How would you describe your relationship to food and your body? What are you struggling with? Do you experience cravings for any particular food?

Have you worked with a nutritionist or weight loss coach in the past? What worked and what didn’t?

What are your top three goals for this year (health related or otherwise)? Are you on your way to achieving them? If not, what do you believe is holding you back?

Why is working with Amanda a financial priority for you this year? What possibilities do you see for yourself after working with Amanda?

How is / was the Health of Your Mother?

How is / was the Health of Your Father?

What Blood Type are You?

How Is Your Sleep?

How Many Hours?

Do You Wake Up at Night?


Any Pain, Stiffness or Swelling?

Constipation / Diarrhea / Gas?

Allergies or Sensitivities? Please Explain.

Are Your Periods Regular?

How Many Days Is Your Flow?

How Frequent?

Reached or Approaching Menopause? Please Explain:

Do You Experience Yeast Infections or Urinary Tract Infections? Please Explain:

Do You Take Any Supplements or Medications? Please List:

Any Healers, Helpers or Therapies with Which You Are Involved? Please List:

What Role Do Sports and Exercise Play in Your Life?

Tell me a little about what your typical daily diet looks like. Remember, the more you share, the more I can help! There’s no judgment, so be honest with yourself and with me.

Do you Cook?

What Percentage of Your Food is Home Cooked?

Where Do You Get the Rest From?

During your time with Amanda, you’ll have the opportunity to ask any questions you desire. Is there anything you want her to know off the bat or any questions you have on your mind at this moment that you’d like to discuss?


I deeply appreciate you taking the time to fill out the health form. 

I can’t wait to connect and learn more about you.