InTake – Carol G. Smallwood

Thank you for taking the time to answer the following questions. Please email the completed version back to me at carol@cgshealthcoach.com 24 hours prior to your Create My Healthy Habits MAP Discovery Session. Be assured that I will keep your information confidential.

Name*
First Last
Phone*
Email*
What is your main health/wellness concern?*
What have you done in the past to work on this issue? (include both alternative and traditional modalities.)*
What has proven effective?*
What is your current diet like? Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat.*
What would you like your health to be 30 days from now? How about 90 days from now? How would you feel if you got this result?*
What obstacles, challenges, and struggles do you come up with regarding diet/lifestyle?*
What do you hope to get out of our time together?*
What are 5 things you LOVE about your life?*

Carol G. Smallwood

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