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In-Person Event: Catharctic Dance
TURN ON Group Program
About Me
Work With Me
Love
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Connect
Hana Ramat Therapy and Coaching
Home
In-Person Event: Catharctic Dance
TURN ON Group Program
About Me
Work With Me
Love
Media
Connect
INTAKE
Please note, all fields are required!
Name
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First Name
Last Name
Email
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Address
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Address 1
Address 2
City
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Zip/Postal Code
Country
Phone
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(###)
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Personal & Goals
Age
*
Date of Birth
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Place of Birth
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Height
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Current Weight
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Weight 6 Months Ago
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Weight 1 Year Ago
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Would you like your weight to be different?
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Yes
No
If yes, what?
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Relationship Status
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Single
Committed
Married
Domestic Partnership
Divorced
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Children
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Pets
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Occupation
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Hours of work per week
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Do you know your purpose?
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Yes
No
State your purpose
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Do you live your purpose?
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What are your primary sources of community?
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What are your main health concerns?
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Will family and/or friends be supportive of your desire to make lifestyle changes?
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Any other information or concerns?
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Health History
At what point in your life did you feel the best?
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Any serious illness/hospitalizations/injuries?
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How is the health of your father?
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How is the health of your mother?
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What is your ancestry?
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Do you sleep well?
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How many hours per night (on average)?
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Do you wake up at night, and if yes, why?
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Any pain, stiffness or swelling?
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Constipation / Diarrhea / Gas? Please explain:
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Allergies or sensitivies? Please explain:
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Do you take any medications or supplements?
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Any healers, helpers or therapies with which you are invovled? Please list:
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What role do sports and exercise play in your life?
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Food & Lifestyle
Breakfast
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Lunch
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Dinner
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Snacks
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Liquids
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Do you crave sugar, coffee, cigarettes or have any addictions (TV, sex, Facebook)?
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What percentage of your food is home cooked?
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Where do you get the rest from?
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Do you cook?
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What is the most important thing you should change about your diet to improve your health?
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How many nights in the past week did you have one drink (alcohol) or more?
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What percentage of your day is your phone out of reach and/or on airplane mode?
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Finish Up
What role, if any, does spirituality play in your life?
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What goals do you have for the next year?
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What are some life goals (Think big)?
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Is there anything else you'd like to share?
*
Thank you!
I’m SO excited to guide you on this transformational journey!
With love,
Hana
