COACH • AUTHOR • SPEAKER
Schedule a call with Tom
First Name (required)
Last Name (required)
Your Email (required)
Emergency Contact Name (required)
Emergency Contact Relationship (required)
Emergency Contact Phone Number (required)
Emergency Contact Email (required)
Date: (required)
Typical daily schedule from wake up to bedtime:
Quality of sleep, number of hours, sleep position:
Typical Breakfast:
Typical Lunch:
Typical Dinner:
Snacks:
Beverages other than water:
How much water per day:
Do you consume caffeinated beverages? What and how much per day?
Do you consume alcoholic beverages? What and how much per day/week?
Treatments/therapies received and currently receiving (effectiveness):
Daily medications and time of day taken:
Daily nutritional supplements:
What are your stress triggers?:
How do you manage your stress?:
Are you in pain? If yes, where?:
Please describe the quality of your pain:
What do you do for your pain?:
What trigger point tools, massage tools, heat, ice, and other self-care items do you use (if different than above)?:
What are the main things that make your pain and other symptoms worse?:
Where do you feel the most work needs to be done to improve your symptoms?:
Daily/weekly exercises for general fitness (how often and how much):
Daily/weekly exercises specific to a health condition (how often and how much):
What activities do you do for fun?:
What are your goals in working with me as your coach:
What is your biggest challenge(s) preventing you from reaching your goal?:
Additional information you feel is important for me to know:
