"FREE" Health Consultation

 

 As your "Health Coach" I will assist you in setting goals and making lifelong changes.

 

To receive your FREE Health Consultation and information about

Kay's one-on-one HEALTH COUNSELING SERVICES,

please fill out and submit the form below.

* Required fields
DATE: *
HOW DID YOU LEARN ABOUT THIS WEBSITE? *
NAME: *
ADDRESS: *
EMAIL ADDRESS: *
HOW OFTEN DO YOU CHECK EMAIL? *
BEST PHONE NUMBER TO REACH ME: *
BEST TIME TO REACH ME: *
DATE & PLACE OF BIRTH: *
AGE & HEIGHT: *
CURRENT WEIGHT: *
WEIGHT SIX MONTHS AGO: *
WEIGHT ONE YEAR AGO: *
WOULD YOU LIKE YOUR WEIGHT TO BE DIFFERENT? IF SO, WHAT? *
RELATIONSHIP STATUS: *
CURRENT NUMBER IN HOUSEHOLD: *
CHILDREN: *
PETS: *
OCCUPATION: *
HOURS YOU WORK PER WEEK: *
HOBBIES & ACTIVITIES YOU REGULARLY PARTICIPATE IN: *
WHAT ROLE DOES SPORTS & EXERCISE PLAY IN YOU LIFE? *
AT WHAT POINT IN YOUR LIFE DID YOU FEEL BEST? *
DO YOU FEEL ALERT OR FOGGY-BRAINED DURING THE DAY? *
DO YOU HAVE UNUSUAL BOUTS OF DEPRESSION, ANGER OR IRRITABILITY? *
DO YOU SLEEP WELL? HOW MANY HOURS? DO YOU WAKE UP AT NIGHT? IF SO, WHY? *
ON A SCALE OF 1 (great) to 10 (awful) HOW DO YOU FEEL WHEN YOU WAKE IN THE MORNINGS? *
WHAT IS THE GREATEST SOURCE OF STRESS IN YOUR LIFE? *
HAVE YOU EVER BEEN EMOTIONALLY, PHYSICALLY, SEXUALLY OR SPIRITUALLY ABUSED OR TRAUMATIZED? *
LIST ANY SERIOUS ILLNESSES, HOSPITALIZATIONS OR INJURIES: *
HOW IS/WAS THE HEALTH OF YOUR MOTHER? *
HOW IS/WAS THE HEALTH OF YOUR FATHER? *
WHAT IS YOUR ANCESTRY?
WHAT BLOOD TYPE ARE YOU?
PLEASE LIST FOODS YOU ATE OFTEN AS A CHILD: *
PLEASE LIST FOODS YOU TYPICALLY EAT TODAY: *
WHAT FOODS ARE YOU SENSITIVE TO? *
HAVE YOU ELIMINATED THEM FROM YOUR DIET? IF SO, FOR HOW LONG? *
DO YOU FEEL WORSE WHEN DEPRIVED OF SUGARS AND CARBOHYDRATES (POTATOES, BREADS, PASTA, SWEETS)? *
DO YOU CRAVE SOFT DRINKS, COFFEE, CIGARETTES OR HAVE AN ALCOHOL OR DRUG ADDICTION? *
WHO COOKS IN YOUR HOME *
DO YOU LIKE TO COOK? *
WHAT PERCENTAGE OF YOUR FOOD IS HOME-COOKED & FROM WHERE DO YOU GET THE REST? *
WILL FAMILY AND/OR FRIENDS BE SUPPORTIVE OF YOUR DESIRE TO MAKE FOOD AND/OR LIFESTYLE CHANGES? *
THE MOST IMPORTANT THING I SHOULD CHANGE ABOUT MY DIET TO IMPROVE MY HEALTH IS: *
PLEASE LIST ALL SUPPLEMENTS AND HERBS YOU REGULARLY TAKE: *
PLEASE LIST ALL MEDICATIONS YOU REGULARLY TAKE: *
HOW MANY TIMES HAVE YOU TAKEN ANTIBIOTICS IN THE LAST YEAR? *
PLEASE LIST ANY HEALERS, HELPERS OR THERAPIES WITH WHICH YOU ARE INVOLVED: *
DOES YOUR ESOPHAGUS MAKE "GURGLING" SOUNDS? *
DO YOU OCCASIONALLY COUGH & STRANGLE DURING OR AFTER EATING? *
DO YOU OFTEN COUGH OR WHEEZE WHEN LYING DOWN? *
DO YOU HAVE SHORTNESS OF BREATH, HEART PAINS, PALPITATIONS OR HIGH BLOOD PRESSURE? *
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?
OTHER:
HOW MANY BOWEL MOVEMENTS DO YOU HAVE DAILY & ARE THEY FORMED? *
DO THEY PASS EASILY & ARE THEY YELLOW, GREY, BROWN OR BLACK? *
IF YOU'VE HAD ANY ABDOMINAL OR GASTROINTESTINAL TRACT SURGERIES, PLEASE EXPLAIN: *
DATE OF LAST COLONOSCOPY AND/OR ENDOSCOPY: *
DO YOU FEEL HOPEFUL OR HOPELESS ABOUT YOUR HEALTH AND/OR DISEASE? *
DO YOU HAVE ANY OTHER CONCERNS OR NEED URGENT HELP WITH ANYTHING?
MAY I ADD YOU TO MY NEWSLETTER MAIL LIST? *


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Kay Stence, AADP Certified Nutrition & Lifestyle Coach

IBD – GF – SCD Digestive Health Counselor

1863 Greenwood Lane, Kingsland, TX 78639           

www.nurturing-lifestyle.com   512-632-3682   www.austinscdfriends.com 

 

 

Kay Stence, CHHC, AADP

Certified Nutrition & Lifestyle Coach

IBD – GF – SCD Digestive Health Counselor

1863 Greenwood Lane, Kingsland, TX 78639           

www.nurturing-lifestyle.com   512-632-3682   www.austinscdfriends.com