Full Name *

Phone *

Email *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (+44) 7456788112 for assistance. You can reply STOP to unsubscribe at any time.

Introduction to Your Pre-Coaching Health Assessment Survey

Welcome!

Thank you for choosing Runyararo Holistic Wellness to partner with you on your journey to optimal health. We are excited to begin this work together!

Why This Survey Matters

This detailed Pre-Coaching Health Assessment Survey is the most crucial first step in our holistic wellness and integrative functional medicine coaching process.

Our approach is highly personalized and focuses on identifying the root causes of your health challenges, not just managing symptoms. To do this effectively, we need a deep, comprehensive understanding of you as a whole person—mind, body, and spirit.

By completing this survey, you enable us to:

Create a Personalized Roadmap: The information you provide allows us to map out your unique health timeline, connect seemingly unrelated symptoms, and understand the core drivers impacting your well-being. This ensures your coaching plan is targeted specifically to your body and your goals.
Maximize Our Time Together: By reviewing your health history, current lifestyle, environment, and wellness goals before our first session, we can dedicate our valuable one-on-one time to developing strategies and action plans immediately, rather than spending that time gathering basic data.
Address Root Causes: Your detailed history of symptoms, sleep, diet, stress, and lifestyle gives us the necessary context to look beyond the surface. We can then apply the Integrative Functional Medicine framework to uncover imbalances in your body's foundational systems (e.g., gut health, hormones, detoxification).

Please answer all questions honestly and thoughtfully. The more accurate and detailed your responses, the more precisely we can tailor your coaching plan to accelerate your journey toward vibrant health, sustained energy, and profound peace.

We look forward to reviewing your assessment and embarking on this transformative path with you!

Primary Goals & Concerns

Please briefly describe the top 3 goals you hope to achieve during our time together (e.g., reduce anxiety, improve digestion, increase energy, manage weight): *

Option 1
Option 2
Option 3

On a Scale of 1-10 (Rate severity) (Option 1) *

On a Scale of 1-10 (Rate severity) Option 2 *

On a Scale of 1-10 (Rate severity) (Option 3) *

Frequency Option 1 *

Frequency Option 2 *

Frequency Option 3 *

Daily Impact:

How do these symptoms impact your daily life, mood, and ability to do the things you enjoy? *

Health Timeline: Major Events-

Please list any major past health events, significant illnesses, or surgeries, and roughly when they occurred (approximate age or year). *

Major Event 1
Major Event 2
Major Event 3

What are your current Medications & Supplements:

Please list all prescription medications, over-the-counter drugs, and nutritional supplements you currently take. *

Major Life Changes:

In the last 5-10 years, what major emotional or physical life changes have you experienced? (e.g., job loss, divorce, major move, loss of a loved one, significant trauma, childbirth) *

Family Health History:-Family Patterns:

Please list any major health issues that run in your immediate family (parents, grandparents, siblings), as these can offer important clues. *

Sleep Quality:

Do you get quality sleep? *

How many hours of sleep do you typically get per night? *

Do you feel rested and refreshed when you wake up? *

Yes

Stress Management:

How do you currently manage stress, and what are your main sources of stress? *

Exercise/Movement:

How often do you move your body in a typical week, and what type of activity is it? *

Nutrition:

Please summarize your typical daily meals and snacks. (A simple summary is fine, e.g., “I eat a plant-based diet,” “Lots of coffee and quick grab-and-go meals,” etc.) 58qj *

Previous Interventions

What healing methods have ypu ried in the past? *

Treatments Tried:

What therapies, treatments (holistic or conventional), diets, cleanses, or interventions have you tried for your current concerns? *

What Worked? Of everything you’ve tried, what gave you the best results? *

What Didn't Work? What was the least effective or most frustrating thing you tried, and why? *