Application form Your Health Coach

  • Step 1:
    Start today!
  • Step 2:
    Health
  • Step 3:
    Consumption
  • Step 4:
    Personal
  • Step 4:
    Done!
  1. Healthy living is a lifestyle!
    To book a consultation at Your Health Coach we would like you to fill out our application form. Within 24 hours you will receive a reply to set up an appointment.

    Step 1: Start Today

  2. 1. Please note down your personal goals (max 100 words)
    Invalid Input
  3. 2. Please note down any blocking factors or thoughts
    Invalid Input
  4. 3. What is your name?
    Invalid Input
  5. 4. Are you male of female?
    Invalid Input
  6. Which Your Health Coach do you prefer?





    Unfortunately it is not always possible to actually assign a Coach of your choise
  1. Step 2: Health
  2. 5. Do you have an active lifestyle or do you work out?
    Invalid Input
  3. How many days a week
    Invalid Input
    times a week
  4. What kind of activity or work out?
    Invalid Input
  5. 6. Do you either feel cold or hot more often?
    Invalid Input
  6. 7. Are you currently in good health?
    Invalid Input
  7. What are your complaints?
    Invalid Input
  8. 8. Did you experience any health complaints in the past?
    Invalid Input
  9. What were your complaints?
    Invalid Input
  10. 9. Do you use any medication or prescription drugs?
    Invalid Input
  11. What medication of prescription drugs do you use?
    Invalid Input
  12. 8. Are you seeing a health professional or specialist?
    Invalid Input
  13. Why?
    Invalid Input
  14. 9. Do you have any allergies or food intolerances?
    Invalid Input
  15. What kind of allergies or food intolerances?
  16. 10. Is there a history of allergies in your family?
  17. Which one?
    Invalid Input
  18. 11. Do you use any food supplements or homeopathic supplements?
    Invalid Input
  19. Which one?
    Invalid Input
  20. 12. Do you have any amalgam (silver) fillings in your teeth?
    Invalid Input
  21. How many fillings?
    Invalid Input
  22. For how long?
    Invalid Input
  23. How many fillings?
    Invalid Input
  24. 13. Have you had any root canal treatments in the past?
    Invalid Input
  25. How many?
    Invalid Input
  26. 14. Do you feel fit upon awakening?
    Invalid Input
  27. 15. Can you fall asleep easily at night?
    Invalid Input
  28. 16. Do you wake up at night to go to the bathroom to pee?
    Invalid Input
  29. 17. Do you wake up at night several times a night?
    Invalid Input
  30. 18. On working days, I get up at
    Invalid Input
  31. 19. In the weekend, I get up at:
    Invalid Input
  32. 20. On working days, I go to bed at:
    Invalid Input
  33. 21. In the weekend, I go to bed at:
    Invalid Input
  34. 22. Do you have a bowel movement every day?
    Invalid Input
  35. How many times a day
    Invalid Input
    times a day
  36. Please describe
    Invalid Input
  37. 23. Do you have intestinal complaints?
    Invalid Input
  38. What are your complaints?
    Invalid Input
  39. 24. What does your bowel movements look like?
    Invalid Input
  40. 25. What is the color of your bowel movements?
    Invalid Input
  41. 26. What is the color of your urine?
    Invalid Input
  42. 27. Did you ever experience a fungal infection of your (toe)nails?
    Invalid Input
  43. How many nails?
    Invalid Input
  44. Since when?
    Invalid Input
  45. 28. Do you experience bleeding, sensitive gums during flossing or brushing your teeth
    Invalid Input
  46. 29. Were you born by a C- section?
  47. 30. Were you breast fed as a baby?
  48. For how long?
  49. 31. How would you describe your libido?
  50. 31.1. Are you pregnant or have given birth recently?
    Invalid Input
  51. 31.2. Do you have children older than 1 year old?
    Invalid Input
  52. How old are your children?
    Invalid Input
  53. 31.3. Please note down how you have experienced your pregnancy:
    Invalid Input
  54. 31.4. Please note down how you have experienced your labor:
    Invalid Input
  55. 31.5. How would you describe your period?
    Invalid Input
    For example: Painful, more than 4 days, light, effortless, irregular, heavy bleedings
  56. 31.6. Do you experience hot flashes, night sweats or other menopausal symptoms?
    Invalid Input
  1. Step 3: Consumption
  2. 32. Do you smoke?
    Invalid Input
  3. What do you smoke?
    Invalid Input
  4. How many a day?
    Invalid Input
    a day
  5. When did you start?
    Invalid Input
  6. 33. Do you drink alcohol?
    Invalid Input
  7. What do you drink?
    Invalid Input
  8. More than 2 servings per week?
    Invalid Input
  9. How many servings at a time?
    Invalid Input
    a time
  10. 34. Do you drink coffee?
    Invalid Input
  11. How many per day
    Invalid Input
    cups per day
  12. How do you drink your coffee?
    Invalid Input
  13. 35. Do you use sugar or sugar containing products like candy (bars), cookies, ice cream etc?
    Invalid Input
  14. What kind of products?
    Invalid Input
  15. Do you use these products on a daily basis?
    Invalid Input
  16. 36. Do you use a microwave to cook or defrost food?
    Invalid Input
  17. How many days a week?
    Invalid Input
    times a week
  18. 37. Do you prefer either a savory or a sweet taste?
    Invalid Input
  19. 38. Do you prefer your drinks hot or cold?
    Invalid Input
  20. 39. Can you skip breakfast easily?
    Invalid Input
  21. 40. Can you skip snacks easily?
    Invalid Input
  22. 41. Can you skip meals easily?
    Invalid Input
  23. 42. Do you crave sweets after a meal?
    Invalid Input
  1. Step 4: Personal
    We would to collect some personal details to connect you for an appointment.
  2. 43. Your name
    Invalid Input
  3. 44. Your address
    Invalid Input
  4. 45. Your postal code
    Invalid Input
  5. 46. Your city
    Invalid Input
  6. 47. Your date of birth
    / / Invalid Input
  7. 48. Your phone number
    Invalid Input
  8. 49. Your e-mail
    Vul hier een geldig e-maila adres in
  9. 50. Your occupation
    Invalid Input
  10. 51. Comments
    Invalid Input
  11. Make an appointment

    Your Health Coach offers you the opportunity to choose a day and time to schedule your appointment. Below you can suggest three dates (with point of time).

  12. Which dates suits you the most?
  13. Voorkeurdatum 1:
    Invalid Input
  14. Which part of the day do you prefer?


    Invalid Input
  15. Voorkeurdatum 2:
    Invalid Input
  16. Which part of the day do you prefer?


    Invalid Input
  17. Voorkeurdatum 3:
    Invalid Input
  18. Which part of the day do you prefer?


    Invalid Input
  19. Type of consultation:

    Invalid Input
  20. Online Toestemmingsformulier Algemene verordening gegevensbescherming (AVG)
    Met dit formulier geef ik Your Health Coach toestemming om gegevens over mij te verwerken zoals beschreven in de privacy verklaring.

    Ik geef toestemming onder deze voorwaarden:
    - Mijn toestemming geldt alleen voor de in dit formulier ingevulde gegevens. Voor nieuwe gegevensverwerkingen vraagt Your Health Coach mij opnieuw om toestemming.
    - Your Health Coach informeert mij over de gegevens die over mij worden uitgewisseld en de gegevens die over mij worden geregistreerd. Dat betekent bijvoorbeeld dat Your Health Coach mij uitlegt om welke specifieke gegevens het gaat en waarom deze gegevens noodzakelijk zijn om mij te kunnen helpen. - Ik ben mij ervan bewust dat het niet geven van toestemming invloed kan hebben op de behandeling van Your Health Coach.
    - Als gegevens niet (meer) noodzakelijk zijn zal Your Health Coach deze niet registreren dan wel verwijderen.
    - Ik kan ervoor kiezen om geen toestemming te geven of om alleen voor bepaalde delen toestemming te geven.
    - Ik mag mijn toestemming op elk moment intrekken.
    - Deze toestemming is tot 2 jaar geldig na afsluiting behandeling.
  21. You must agree with these terms before you sign up.
  22. You must agree with these terms before you sign up.

    Not all fields are filled out correctly. Fields marked in green must be completed.