About You | Ask Amy

Medications you are taking:

Nutritional Supplements you take regularly:

Please describe your use of caffeine, nicotene, alcohol & other substances:

If you answered yes to either question above, please explain the major details of your medical issue/s.

Medical or Alternative/Complementary Practitioners you work with (include all specialists consulted in the past 10 years.) If you still work with them and wish for me to coordinate care, please list their name and how to contact: (UPLOAD ANY PERTINENT LABS, ORTEST RESULTS BELOW):

Other Possible Stressors (briefly decribe current relationship struggles, children and/or other loved ones cared for, etc.)

Foods You Love (even if you think you shouldn't):

Foods You Hate (or avoid for religious reasons):

Do you enjoy cooking? Why/Why not?

Where and how do you usually shop for food?

Do you eat out? Where & When?

Please describe your current usual eating pattern:

Please decribe any struggles or frustrations you experience around eating. How would you describe your current relationship with food and your body?

What do you hope to achieve or accomplish through coaching?

Past Medical History

Family Medical History

Social History