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The​​ Mind Body​​ Questionnaire

This document has been designed as the first stage of your coaching process. As the client, the more information you can provide, the more your coach will be able to deliver the best service​​ to​​ help you achieve your goals.

 

Part 1:​​ Your​​ Contact​​ Details​​ -​​ Please complete where appropriate

 

Name:​​ 

D.O.B:

Address:​​ 

Today’s Date:​​ 

 

Email​​ Address:​​ 

Mobile Number: ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​ ​​​​ Prefer text? Then check the box □

Work Number:​​ 

Home Number:​​ 

 

Please attach a headshot of yourself below:

 

 

 

 

 

 

Instructions

  • Create some time to focus on completing this form. Please fill out the form to the best of your ability. If you are unsure of anything,​​ or of what answer to give,​​ you can check with your coach on your first call.

  • Put yourself in a​​ good​​ state.

  • You are about to clarify and set your primary​​ health​​ outcome for your life.​​ Get excited!

  • Your goals may change in time - this is fine,​​ but do not spend your time trying to fix what is not perfect with what you have written. Accept that whatever you have done is perfect right now.

  • Now complete the remainder of the Questionnaire, remember to be detailed as possible.​​ 

  • Email this to me once you’re finished​​ [email protected].

  • Remember to keep a copy close at hand. It is a great idea to review it regularly and you will need to look back over what you have written prior to each coaching session.​​ 

 

Part 2:​​ You and Your Life Now

 

  • What are you currently doing in your life/career/business?

 

 

  • List and describe the most important relationships in your personal life at this time?​​ (e.g. partner, family, children, friends).

 

 

  • What do you enjoy?​​ What​​ are you passionate about?

 

  • What motivates and excites you?

 

  • What are the​​ things in your life​​ right​​ now that you are most proud of,​​ and​​ most pleased and satisfied with?

 

 

  • What are the biggest frustrations, disappointments, challenges or failures that you are currently experiencing?

 

  • How long have you had these frustrations, disappointments, challenges or failures?

 

  • What have​​ these cost​​ you?​​ 

(Think of time, money, lost opportunities, relationships, health, etc. Please be specific.)

 

  • What has stopped you​​ from​​ overcoming your current frustrations, disappointments, challenges, or failures?

 

  • What will your current frustrations, disappointments, challenges or failures continue to cost you if you don’t overcome them?

 

  • Score each of these areas of your life out of 10.

  • Health and Wellness​​ ( ​​ )

  • Relationships and Romance ( ​​ )

  • Family and home life​​ ( ​​ )

  • Personal development​​ ( ​​ )

  • Career/Business​​ ( ​​​​ )

  • Finances​​ ( ​​​​ )

  • Success/Fulfilment​​ ( ​​​​ )

  • Contribution​​ ( ​​​​ )

 

  • Thinking about the area of your life you identified above, please answer the following questions:

 

    • What is the specific problem or issue in this area of your life?

 

    • How do you know you have this problem?​​ 

 

    • What have you done in the past to change this situation?

 

    • How will you know when your obstacles have gone? What will you think and feel?

 

 

    • When you have overcome your problem, what will you be able to do/​​ be that you can’t now?

 

    • What resources do you have and​​ what​​ would help you to get what you want?

 

  • Please list​​ your top 10 values​​ in relation to your life. What is most important to you in the context of your life at this time?

 

  • What course have you completed so far in respect of educational courses, NLP,​​ etc.?

 

  • ​​ What is your preferred​​ representational system?​​ 

 

Visual, auditory,​​ kinaesthetic, or auditory digital​​ 

 

(This is an optional question – if you are not sure, wait to speak with your coach during your first session.)

 

 

Part 3:​​ Primary​​ Motivation​​ and Grand Purpose

 

  • What is your primary​​ motivation​​ for enrolling in and completing this​​ health​​ coaching?​​ 

 

 

  • What do you want to achieve from working with​​ me?​​ 

(Think now, and consider…make this​​ health​​ outcome so big, so exciting that, when you achieve it, it would make your experience in coaching the most important and significant experience of your life.)​​ 

 

 

  • Why is this so important to you?

(What is the deep, driving reason for achieving your​​ primary​​ health​​ outcome? Make this purpose statement so big and juicy that it inspires you, propels you forward and creates a total desire to succeed. Remember, include how this achievement will affect the lives of your loved ones, those around you and the planet as a whole.)​​ 

 

 

 

Part 4:​​ About YOUR coaching

 

  • What are the top​​ things/criteria you want in a coach?

 

 

  • Are there any special​​ ways your coach can support you through this process?

 

 

  • For this process to be truly successful​​ do you feel​​ does your coach need to be/do?

 

  • For this process to be truly successful​​ is there anything special that​​ you need to be/do?

 

 

Part 5:​​ About Your Health Goals

 

  • In 12​​ months,​​ my​​ health​​ will be…?

 

  • Have you​​ already​​ set any​​ health​​ goals for yourself?​​ ​​ If not, what has stopped you?

 

  • How have you captured those goals?

 

  • What are your most important lifetime goals?

 

  • What are your most important one-year goals?

 

 

 

Part 6:​​ In​​ Summary

 

  • What is​​ your​​ desired​​ outcome for this coaching program?

 

  • How will you know you have achieved this outcome?

 

  • Please choose​​ 1​​ health​​ goal​​ that you want to work on with your coach immediately.

 

 

 

Part 7:​​ Your​​ Health​​ Intake

 

Height:

Weight:

Relationship​​ status:​​ 

Divorced / Single / Widowed / Married / Living with Partner / Separated / Other​​ 

Occupation:

Physician:

Your main​​ health​​ concern:​​ 

 

 

 

When did​​ this​​ condition start? ​​ _____________________ ago.

 

    • Heat makes it:​​ 

better/ no change / worse

 

    • Cold makes it:​​ 

better/ no change / worse

 

    • Damp weather:​​ 

better/ no change / worse

 

    • Exercise / Activity:​​ 

better/ no change / worse

 

Your​​ Health​​ History

Check any that apply below​​ and​​ write “in family” if there is family history​​ with any illnesses below:

□ Cancer (types?)

□ Diabetes (types?)

□ Hepatitis

□ High Blood Pressure

□ Heart Disease

□ Stroke

□ Seizure Disorder

□ Thyroid Disease

□ Asthma

□ Pacemaker

□ Osteoporosis

□ Herpes

□ AIDS / HIV

□ Other STD

□ Rheumatic Fever

□ Alcoholism

□ Allergies (types?)

□ Mental Illness

□ Kidney Disease

□ Anaemia

 

 

Your Health​​ Habits

Write your amount of each per week beside each listed below:

  • Coffee / Tea

  • Soda

  • Tobacco

  • Alcohol

  • Drugs

 

Your​​ Exercise

Do you exercise regularly?

If so, what​​ do you do​​ and how often?

 

Your​​ Diet

Do you have a special diet now or in the past?

(Vegetarian, vegan, raw, Atkins, etc.)

 

Your​​ Medications

Please note what medications, herbs or supplements that you take regularly

 

Your​​ Injuries & Surgeries

Please​​ write out​​ what happened to​​ any​​ area​​ of your body​​ and when it occurred (include dental issues)

 

Your​​ Temperature

How warm/ cold you feel (not in degrees); relative to other people – do you wear more or less layers, etc.?​​ 

 

Check any​​ below​​ that are applicable and write details below:

□ Cold hands or feet

□ Chills

□ Cold in the bones

□ Areas of numbness

□ Thirst, no desire to drink

□ Absence of thirst

□ Excessive thirst

□ Night sweats

□ Unusual sweats – when and where on the body?

□ Hot hands, feet, chest

□ Hot flashes

□ Hot in afternoon

□ Hot at night

 

 

Your​​ Moisture

How is your overall body moisture? (hair, skin, mouth, bowels, etc.)​​ Check any that are applicable and write details below.

□ Dry skin

□ Dry hair

□ Dry eyes

□ Dry brittle nails

□ Dry mouth

□ Dry lips

□ Dry throat

□ Dry nose / nosebleeds

□ Edema / swelling

□ Rashes

□ Itching (where on your body?)

□ Dandruff

□ Oil skin

□ Oily hair

□ Pimples

□ Weight gain / loss

 

Your​​ Digestion

​​ BM: How often? ​​ ___​​ x’s/ each​​ ____day?

​​ Alternating diarrhoea & constipation (IBS)

​​ Indigestion

​​ Gas

​​ Bloating

​​ Belching

​​ Poor appetite

​​ Nausea / Vomiting

​​ Bad Breath

​​ Heartburn

□ Excessive hunger

□ Dry Stools

□ Difficult to pass

□ Tired after BM

 

Your​​ Energy

​​ Sudden energy drop / time of day: ___​​ am/ pm

​​ Energy drop after eating

​​ Fatigue

​​ Dependence on caffeine / stimulants

​​ Wired / ungrounded feeling

​​ Body / Limbs feel heavy

​​ Body / Limbs feel weak

□ Shortness of breath

□ Heart Palpitations

□ Blood pressure Hight / Low

□ Bleed / Bruise easy

□ Hard to Concentrate

□ Poor memory

□ Dizziness / Lightheaded

□ Headaches ____ x’s​​ / week

 

Your​​ Sleep

How many hours per night?

​​ Difficulty falling asleep

​​ Wake ___ x’s/ night at ___ am / pm

□ Wake to urinate – how often?

□ Disturbing dreams

□ Restless sleep

□ Not rested upon waking

THE MIND BODY QUESTIONNAIRE

 

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Your​​ Emotions

What emotions dominate your experience?

□ Anger

□ Irritability

□ Anxiety

□ Worry

□ Obsessive thinking

□ Sadness

□ Grief

□ Depression

□ Joy

□ Fear

□ Timid / Shy

□ Indecision

 

Your​​ Eyes,​​ Ears,​​ Nose,​​ Throat

□ Poor vision

□ Night Blindness

□ Red eyes

□ Itchy eyes

□ Spots in front of eyes

□ Sinus congestion

□ Phlegm

□ Poor hearing

□ Ringing in ears

□ Excess earwax

□ Sore throat

□ Dental problems

□ Mouth sores Cough

 

Your​​ Urine

Fluid in = Fluid out? ​​ □ Y ​​ □ N ​​ 

□ Decrease in flow

□ Dribbling

□ Difficulty starting / stopping

□ Incontinence

□ Kidney stones

□ Urgency to urinate

□ Frequent urination

□ Pain on urination

□ Burning sensation

□ Cloudy urine

□ Blood in urine

 

 

Your​​ Reproductive​​ Organs​​ (if applicable)​​ 

Are you sexually active: ​​ □ Y ​​ □ N

□ Change of sexual drive

□ Erectile dysfunction

□ Premature ejaculation

□ Sores on genitals

□ Discharge

□ Prostate disease

□ Genital pain

□ Jock itch

□ Vasectomy

□ Hernia

□ Haemorrhoids

 

Are you receiving government benefits​​ or is someone supporting you?​​ □Y ​​ □N

If yes, are you aware that this could cause a conflict-of-interest to your healing program?​​ Consult​​ with​​ your coach.

 

 

Identification of Pain or Discomfort in Your Physical Body

With a black pen, coloured pencil or crayon, draw small circles on the diagram below where physical pain or discomfort exists in your physical body.​​ Draw any​​ part of your​​ body​​ which is not working optimally.

 

 

 

 

 

Please​​ read the Disclaimer:

Information during this coaching​​ program​​ is for educational purposes only. It is not intended to diagnose, prescribe, treat or cure any disease or mental condition.​​ The outcome in this program is the sole responsibility of the client.​​ The FDA has not evaluated this information and I make no curative claims.

 

□ Check the box if you have read the disclaimer and understand that all outcomes are the sole responsibility of the client.

 

 

That’s it! You’re finished​​ - good job!​​ 

Now email​​ this questionnaire​​ to me at​​ healwithm[email protected]

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THE MIND BODY QUESTIONNAIRE