Beyond Nutrition Balanced Solutions Life Coach Executive Coach Individual and Corporate Wellness Nutritionist Health Food Healthy Living Organization Personal Training

Personal Information:

Name: Address: Email Address How often do you check email? Best number to reach you:

Age: Height: Date of Birth mm/dd/yyyy: Place of birth: Current weight: Weight six months ago: One year ago: What is your ideal weight? What is your Body Mass Index (BMI)? What is your waist size? Do you have small, med or large bones:

Social Information:

Relationship Status: Do you have children: If so, how many? Grandchildren: If so, how many? Pets:

Occupation: Hours per week of work: What is your retirement plan: Are you part of a community? Please explain: Do you still feel independent:

Health Information:

Please list your main health concerns: Other concerns: At what point in your life did you feel best: Any serious illnesses, hospitalizations, and/or injuries? How is/was the health of your mother? How is/was the health of your father? What is your ancestry:

What role does exercise play in your life? Is your energy level low, med, or high? Do you sleep well? How many hours?
Do you wake up at night: If so, why? Any pain, stiffness or swelling? Please explain: Constipation/Diarrhea/Gas? Please explain: Allergies or sensitivities? Please explain:

Medical Information:

Do you take any supplements or medications? Please list: Any healers, helpers or therapies with which you are involved? Please list:

What is your blood type? What is your HDL/LDL cholesterol? What is your blood pressure?

Diet Information:

1. What foods did you eat as a child?

- Breakfast:
- Lunch:
- Dinner:
- Snacks:
- Liquids:

2. What is your food like these days?

- Breakfast:
- Lunch:
- Dinner:
- Snacks:
- Liquids:

What percentage of your food is home cooked? Where do you get the rest from? Do you crave sugar, coffee, cigarettes, alcohol or have other addictions?

Additional Information: Will family and/or friends be supportive of your desire to make food and/or lifestyle changes? What is the most important thing you want to change about your diet? How did you hear about Marianne Bellino and Beyond Nutrition Balanced Solutions? Anything else you want to share? What are your top 3 health/life goals?