First Name:

Last Name:

Phone Number:

Email:

Mailing Address:

Age:

D.O.B.:

Gender:

Height:

Weight:

Marital Status:

Number of Children and Their Ages:

Employer:

Occupation:

Name of Emergency Contact:

Phone Number of Emergency Contact:

Relationship to Emergency Contact:

Please Identify Your Primary Concern:

Please Identify Your Secondary Concern:

Please Identify Your Third Concern:

Have/Are Any of These Concerns Been/Being Treated?

If Yes, When, and by Whom?

What Type of Treatment(s) Have Your Tried?

What Were the Results?

Please Describe Your Health Goals:

List All Medications You Take, What You Take It For and How Long You Have Been Taking Them:

List All Supplements You Take and How Long You Have Been Taking Them:

For Women:  Are You Nursing:

For Women:  Are You Cyclic?

For Women:  Are You On Birth Control?

For Women:  Date of Last Cycle

I certify, to the best of my knowledge, that all the above information is accurate.  (Enter Your Full Name Below)

Date Signed

HEALTH COACH DISCLAIMER:

An Elevation Health Coach facilitates the process of balancing your body and helps you move closer to your wellness vision by creating a personalized and strategic action plan.

You can expect your coach to listen with curiosity and empathy, ask powerful questions and hold you accountable to your commitments.

Through coaching, you are empowered to initiate change and set personally motivating session goals to address a variety of concerns, such as stress, lab reports, diet, exercise, nutrition, supplementation, and relationships.

Throughout the process, your coach will work beside you as a collaborative partner on your journey, helping draw out of you what you already know, believe, and desire.

Coaching services are not medical advice, nor do they replace services such as those provided by Registered Dieticians, Physical Therapists, Medical Doctors, Nurse Practitioners, or any other health professional.

Elevation Health Coaching services is a supplemental service to any of those health-related services you may need to pursue. 

Although the doctors are licensed Chiropractors in the state of California, they are working with you as a health coach and not a chiropractor.

Health coaching considers mind, body, and spirit in terms of thoughts, beliefs, and behavior empowering you to make positive changes in your life to feel more fulfilled with your overall wellness.

Health Coaching is designed for informational purposes, and our health coaches do not diagnose or treat any medical conditions.

You acknowledge and agree that it is your responsibility to discuss your health and wellness information with your primary care provider as necessary.

Health coaching is a collaborative process that requires active and invested participation.

Successful Health Coaching is largely dependent on your willingness to define and accept goals and try new approaches and follow the plan designed for you.

You are ultimately responsible for the choices, plans, timing, and actions you take.

I have read, understand, and agree with the above. I hereby consent to and acknowledge my voluntary participation in Elevation Health Coaching.

******

Please enter your full name and date in the box below to confirm that you have read and acknowledged the health coach disclaimer.

Date Signed