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)
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  3. 2. Please note down any blocking factors or thoughts
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  4. 3. What is your name?
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  5. 4. Are you male of female?
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  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?
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  3. How many days a week
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    times a week
  4. What kind of activity or work out?
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  5. 6. Do you either feel cold or hot more often?
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  6. 7. Are you currently in good health?
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  7. What are your complaints?
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  8. 8. Did you experience any health complaints in the past?
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  9. What were your complaints?
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  10. 9. Do you use any medication or prescription drugs?
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  11. What medication of prescription drugs do you use?
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  12. 8. Are you seeing a health professional or specialist?
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  13. Why?
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  14. 9. Do you have any allergies or food intolerances?
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  15. What kind of allergies or food intolerances?
  16. 10. Is there a history of allergies in your family?
  17. Which one?
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  18. 11. Do you use any food supplements or homeopathic supplements?
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  19. Which one?
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  20. 12. Do you have any amalgam (silver) fillings in your teeth?
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  21. How many fillings?
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  22. For how long?
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  23. How many fillings?
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  24. 13. Have you had any root canal treatments in the past?
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  25. How many?
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  26. 14. Do you feel fit upon awakening?
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  27. 15. Can you fall asleep easily at night?
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  28. 16. Do you wake up at night to go to the bathroom to pee?
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  29. 17. Do you wake up at night several times a night?
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  30. 18. On working days, I get up at
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  31. 19. In the weekend, I get up at:
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  32. 20. On working days, I go to bed at:
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  33. 21. In the weekend, I go to bed at:
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  34. 22. Do you have a bowel movement every day?
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  35. How many times a day
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    times a day
  36. Please describe
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  37. 23. Do you have intestinal complaints?
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  38. What are your complaints?
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  39. 24. What does your bowel movements look like?
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  40. 25. What is the color of your bowel movements?
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  41. 26. What is the color of your urine?
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  42. 27. Did you ever experience a fungal infection of your (toe)nails?
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  43. How many nails?
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  44. Since when?
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  45. 28. Do you experience bleeding, sensitive gums during flossing or brushing your teeth
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  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?
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  51. 31.2. Do you have children older than 1 year old?
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  52. How old are your children?
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  53. 31.3. Please note down how you have experienced your pregnancy:
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  54. 31.4. Please note down how you have experienced your labor:
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  55. 31.5. How would you describe your period?
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    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?
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  1. Step 3: Consumption
  2. 32. Do you smoke?
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  3. What do you smoke?
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  4. How many a day?
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    a day
  5. When did you start?
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  6. 33. Do you drink alcohol?
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  7. What do you drink?
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  8. More than 2 servings per week?
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  9. How many servings at a time?
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    a time
  10. 34. Do you drink coffee?
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  11. How many per day
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    cups per day
  12. How do you drink your coffee?
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  13. 35. Do you use sugar or sugar containing products like candy (bars), cookies, ice cream etc?
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  14. What kind of products?
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  15. Do you use these products on a daily basis?
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  16. 36. Do you use a microwave to cook or defrost food?
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  17. How many days a week?
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    times a week
  18. 37. Do you prefer either a savory or a sweet taste?
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  19. 38. Do you prefer your drinks hot or cold?
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  20. 39. Can you skip breakfast easily?
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  21. 40. Can you skip snacks easily?
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  22. 41. Can you skip meals easily?
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  23. 42. Do you crave sweets after a meal?
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  1. Step 4: Personal
    We would to collect some personal details to connect you for an appointment.
  2. 43. Your name
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  3. 44. Your address
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  4. 45. Your postal code
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  5. 46. Your city
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  6. 47. Your date of birth
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  7. 48. Your phone number
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  8. 49. Your e-mail
    Vul hier een geldig e-maila adres in
  9. 50. Your occupation
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  10. 51. Comments
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  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:
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  14. Which part of the day do you prefer?


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


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


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  19. Type of consultation:

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  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.

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