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Apply for Coaching

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Personal Information
Please complete all the fields. Your information will remain confidential.
First Name:*
Last Name:*
Email Address:*
How often do you check email?
Mobile Phone:
Home Phone:
Work Phone:
Height:
Age:
Birthdate:
Place of Birth:
Current weight:
Weight six months ago:
Weight one year ago:

Social Information
Relationship status:
Children:
Pets:
Where do you currently live?
Occupation:
Hours of work per week:

Health Information
Please list your main health concerns:*
Other concerns and/or goals?*
At what point in your life did you feel best?*
Any serious illnesses/hospitalizations/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?
Anything else you'd like to let us know?
How is your sleep?
How many hours?
Do you wake up at night?
Why?
Any pain, stiffness, or swelling?
Constipation/Diarrhea/Gas?
Allergies or sensitivities? Please explain:

Women's Health
Are your periods regular?
How many days is your flow?
How frequent?
Painful or symptomatic? Please explain:
Reached or approaching menopause? Please explain:
Birth control history:
Do you experience yeast infections or urinary tract infections? 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 role does exercise play in your life?

Food Information
What foods did you eat often as a child?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:

What is your food like these days?
Breakfast:
Lunch:
Dinner:
Snacks:
Liquids:
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Do you cook?
What percentage of your food is home-cooked?
Where do you get the rest from?
Do you crave sugar, coffee, cigarettes, or have any major addictions?
The most important thing I should do to improve my health is:

Additional Comments

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Dr. Cori Cooper is a pharmacist, certified diabetes care and education specialist, a Life and Health Coach specializing in women's health.

DR. CORI COOPER

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