Wellness Blooms

Health Coaching with Sharon Lees

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Update Form

What positive changes have you noticed since your last appointment?

What are your main concerns at this time?

Any changes with weight and/or waist size?

How is your sleep?

Constipation or diarrhea? Gas or bloating? Which?

How is your mood?

Is your energy level higher or lower lately?

To what do you attribute this energy level?

Are you in any pain on a regular basis? Please describe.

If this is ongoing pain, is it better, same, or worse than before?

Are you receiving good support from those around you for the changes you are making?

Are you taking all supplements consistently? Any concerns?

What do you see as a significant barrier to you making more/faster progress toward your health goals?

Are you cooking more?

What do you crave?

What are you doing or feeling when you crave?

What's your food like these days?
Symptom Questionnaire

Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two weeks. If multiple choices are given, please specify what applies in the comment column.

  • 0 - Never have the symptom.
  • 1 - Occasionally have it and the effect is mild.
  • 2 - Occasionally have it and the effect is severe.
  • 3 - Frequently or Consistently have it and the effect is Mild
  • 4 - Frequently or Consistently have it and the effect is Severe





Stuffy nose

Sinus problems

Hay fever

Sneezing attacks

Excessive mucus formation

Chronic coughing

Gagging or frequent need to clear throat

Sore throat, hoarseness, or loss of voice

Swollen or discolored tongue, gums, or lips

Chronic tooth or gum pain or jaw pain. Which?

Canker sores


Hives or other allergic breakout

Rash or persistently dry skin

Hair loss

Flushing or hot flashes

Frequently feel cold

Excessive sweating

Part of body frequently feeling numb. Which?

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

Nausea or vomiting



Bloated feeling

Belching, burping

Passing gas, flatulence


Intestinal or Stomach pain. Which?

Other pain in GI tract? Where?

Pain or aches in joints


Stiffness or limitation of movement

Pain or aches in muscles

Tremor or restless leg

Feeling of weakness or tiredness

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention


Fatigue, sluggishness

Apathy, lethargy



Poor memory

Confusion, poor comprehension

Poor concentration or focus

Poor physical coordination

Difficulty in making decisions

Stuttering or stammering

Learning disabilities

Mood swings

Anxiety, fear, nervousness

Anger, irritability, aggressiveness


Other mood challenges?

Frequent illness

Frequent or urgent urination

Inability to urinate or low urine flow

Low libido or other sexual dysfunction

Genital itch or discharge

Women: Breast fibroids

Women: Painful or tender breasts

Women: Uterine fibroids