Intrinsic Mind Holistic Health & Wellness
Intrinsic Mind Services
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Student Survey 2020
Indicates required field
Date of Birth
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 when 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
Do you or did you ever smoke?
No But Used to
Yes but only on socially
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
No Not Needed, I give consent
Please indicate if you have any of the conditions listed below
Allergies and Asthma
Active infectious disease (fever, cough etc)
Cervical Spine Problems
Soft tissue contraindication
Open wounds and cuts
Brain or aortic aneurysms
High blood pressure
Deep vein thrombosis
Coagulation & Platelets
Anticoagulant therapy - Coumadin, Warfarin or Heparin
Other platelets or coagulation
Other - More information
Please indicate if you hold TENSION in the body, if so where?
Please indicate if you have CRAMPING in the body, if so where?
Please indicate if you have NUMBNESS in the body, if so where?
Please indicate if you have PAIN in the body, if so where?
Do you have any movement restrictions for us to be made aware of?
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
3/373 Glen Osmond Road, Glen Osmond
0406 939 090
0438 520 219
We aim to respond within 24 hours
Intrinsic mind wellness
"Believe, Achieve, Succeed"
Copyright © Leisa Timms & Jen Ince 2016.
Intrinsic Mind Holistic Health & Wellness Pty. Ltd. All Rights Reserved