Intake Form

Please complete upon booking your consultation.

Truly Living Consult Intake Information

Please take the time you need to complete these questions and submit not later than 3 days before your first session so I can review and be prepared to serve you at the highest level. The information you provide will help to guide your path forward with greater clarity and understanding. I look forward to supporting you in bringing the pieces together to truly live again!

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Gender:

Height:

Current Weight:

Please share your main health concerns:

Of all the changes you'd like to make to your health, please list the top 3 that you feel are most important to you.

Are you currently under a doctor's care? If YES, describe what you are seeing a doctor for.

Please list all known allergies.

Please list any prescriptions / medications (including over the counter) you are taking. Please include the brand, dosage and frequency.

Please list any supplements you are taking. Please include brand, dosage and frequency.

Any pain, stiffness or swelling?

How often do you have a bowel movement? Please describe the consistency of your stools. (Hard, soft, loose, runny/watery, slimy/mucus, foul smelling, etc.)

Please describe your current diet.

Please detail a typical day with Breakfast / Lunch / Snacks / Dinner / Liquids:

Do you consume sugar, chocolate, caffeine, cigarettes, alcohol, recreational drugs or have any major addictions? Please specify daily consumption.

Please check anything that is CURRENTLY a health challenge:

Constipation

Diarrhea

What are some of your favorite things to do that make you feel like you're truly living?

What is your WHY for wanting to heal? What goals / vision do you have for your life?

In order to better serve you and your desire to heal, I use intuitive testing as part of the healing process. Please check below for your approval of this healing process.

I approve

I do NOT approve

What date was your health at its worst?

Month

Day

Year

Do you have any additional questions, concerns or anything else you'd like to share?

How did you find out about Truly Living?

Disclaimer: Truly Living consultations are not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Trained Health Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician's care. As your health/wellness coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals / recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals. As the client, you have the ability to give your informed consent, and hereby give such consent to Truly Living LLC / Krista Moczygemba to assist you in achieving such goals and understand that results are not guaranteed. As the client, you are fully responsible for your well-being during your consultations, and subsequently, including your choices and decisions. The information and opinions expressed by Truly Living LLC / Krista Moczygemba, including outside materials such as documents, blog posts, recordings, videos, programs, and books, are intended for informational purposes only. Do not disregard professional medical advice or delay in seeking professional advice because of any information obtained from Truly Living LLC / Krista Moczygemba. If you have or suspect that you have a medical problem, contact your health care provider promptly. Consult your own Medical Professional regarding all nutritional, herbal or homeopathic supplements to evaluate if the supplements could adversely affect or react with any medications or pre-existing conditions. Stop any food or supplement immediately if you have any type of adverse reaction. Information provided by Truly Living LLC / Krista Moczygemba and the use of any products or services purchased by you DOES NOT create a healthcare provider-patient relationship. Truly Living LLC / Krista Moczygemba are not acting in the capacity of a doctor, licensed dietician, psychologist or any other licensed/registered professional. Truly Living LLC / Krista Moczygemba will not diagnose, treat, or cure in any manner, any disease, condition, or other physical or mental human ailment. Truly Living LLC / Krista Moczygemba makes no guarantees or promises regarding the results you will achieve from participating in their program or services. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.