""
1


NLP Life Coaching Health Questionnaire
First name
Surname
Date of Birth
Address
0 /
Postcode
0 /
Tel:
0 /
Please read the questions carefully and answer each one honestly, ticking the appropriate box or adding information if necessary. Your response will of course be kept in the strictest of confidence.
Question Number
YesNo
1) Are you currently seeing a doctor or health professional for mental illness or any other illness
2) Are you currently taking any prescription medication?
3) Do you smoke? ( If yes please advise daily amount in the box below)
4) Do you take recreational drugs? (If yes, please provide more details below)
5) Do you or your family have a history or epilepsy?
Do you drink alcohol?pick one!
Rateyour sleep pattern
Rateyour mood pattern
Rateyour appetite
If you have answered YES to any of the questions above, please enter the question number and a brief description of the medication and condition below.
Question Number & Further DetailsMedication/Condition/Details
0 /
In the interests of your own health & wellbeing we may request that you consult with your doctor to help us establish your starting point of exercise. All personal information provided will be treated in the strictest of confidence.
IF YOUR HEALTH CHANGES SO THAT YOU MAY THEN ANSWER ‘YES’ TO ANY OF THESE QUESTIONS, YOU MUST INFORM A MEMBER OF STAFF AS SOON AS POSSIBLE.
What would you like to get out of your NLP Life Coaching session?
0 /
Please state preferred time / days for your session
1st choice
Time
0 /
2nd
Time
0 /
3rd
Time
0 /
Agreement
Declaration:
Date
Previous
Next