1-on-1 Counseling - Rootdown Raenen

Personal Information

Full Name(Required)

Date of Birth(Required)

Phone Number(Required)

Email Address(Required)

Address(Required)

Street Address

Emergency Contact Name & Phone(Required)

Health History

Current Health Concerns or Diagnoses(Required)

Relevant Past Medical History (illnesses, surgeries, injuries)(Required)

Current Medications and Dosages(Required)

Current Supplements (vitamins, herbs, etc.)(Required)

Family Medical History

Lifestyle & Habits

Typical Daily Schedule(Required)

Occupation & Work Hours(Required)

Physical Activity (type, frequency, duration)(Required)

Sleep Patterns (bedtime, wake time, quality)(Required)

Stress Levels & Sources(Required)

Caffeine, Alcohol, and Tobacco Use(Required)

Diet & Nutrition

Current Eating Pattern (meals, snacks, timing)(Required)

Food Allergies or Sensitivities(Required)

Foods You Strongly Dislike(Required)

Preferred Cuisines or Ingredients(Required)

Special Dietary Requirements (Vegan, Gluten-Free, etc.)(Required)

Typical Fluid Intake (water, other drinks)(Required)

Goals & Expectations

Primary Goals for Counseling(Required)

Specific Weight, Energy, or Symptom Targets(Required)

Other Lifestyle Goals (sleep, stress, fitness, etc.)(Required)

Biggest Challenges in Reaching These Goals(Required)

Support Systems (friends, family, community)(Required)

Additional Notes

Anything Else You'd Like to Share(Required)

Release of Liability

I acknowledge that the nutrition and wellness counseling provided by Rootdown Raenen is intended for educational and informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. I understand that any changes to my diet, exercise, or lifestyle are undertaken voluntarily and at my own risk. I release Rootdown Raenen, its practitioners, and affiliates from any and all liability arising from the use or misuse of the information provided.

Signature

Date

1-on-1 Counseling per month(Required)

1-on-1 Counseling

Total

Credit Card