0438 520 219 | 3/373 Glen Osmond Road, Glen Osmond, SA 5064 myintrinsicmind@gmail.com

NLP Hypnosis Health Questionnaire

Please fill out the Questionnaire and Consent Form Below.

Consent for Coaching

I have read, completed and understood everything within this questionnaire. All questions were answered truthfully and to the best of my ability. It is understood that the purpose of this coaching is to assist the client in achieving their goals.  I have informed my coach about my state of my health and I have transmitted to them any recommendations and restrictions on the part of my medical doctor or therapist insofar as Personal Training is concerned.

**We aim to get back to you within 24 hours**

    What are your goals and expectations of this coaching? What areas would you like to see changed?*

    Personal Wellness (please click on drop down and/or comment where appropriate)

    How would you rate your level of commitment (5 being excellent and 1 being poor)? *

    How would you rate your level of stress (5 being very High to none and 1 being very Low)? *

    How would you rate your level of fitness (5 being excellent and 1 being poor)? *

    How would you rate your personal motivation (5 being very high and 1 very low)? *

    Do you follow a specific diet? vegetarian, vegan, raw etc. *

    If yes, please describe

    What do you really value in life*

    What is stopping you from being successful in dealing with your challenges? *

    Have you experienced NLP or Hypnotherapy? If yes, briefly describe the experience *

    Did you ever smoke?*

    Additional Comments Welcome

    Personal Health (please click on drop down and/or comment when appropriate)

    Are you on any Medication*

    If yes do you have the doctors go ahead*

    Please indicate if you have any of the conditions listed below

    Coagulation & Platelets

    Cardiovascular Disease

    Joint Problems

    Soft tissue contraindication

    Other, Please Describe

    Do you hold any TENSION in your body, if so where?

    Do you have any NUMBNESS in your body, if so where?

    Do you have any MOVEMENT RESTRICTIONS for us to be made aware of, if so where?

    Do you have any CRAMPING in your body, if so where?

    Do you have any PAIN in your body, if so where?

    Do you have any additional comments that you would like to inform your Practitioner prior to your appointment?

    I consent that the above is relevant and correct information.

    I have read, completed and understood everything within this questionnaire. All questions were answered truthfully and to the best of my ability. It is understood that the purpose of this coaching is to assist the client in achieving their goals. I have informed my coach about my state of my health and I have transmitted to them any recommendations and restrictions on the part of my medical doctor or therapist insofar as Personal Training is concerned.

    I hereby consent to my coaching session*



    Date*

    3/373 Glen Osmond Road,
    Glen Osmond, SA 5064

     

    Jen 0406 939 090
    Leisa 0438 520 219

    myintrinsicmind@gmail.com

    Skype: intrinsic_mind