Making Changes with Miya- Health Survey
Thank you for taking our survey!
Full Name
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First Name
Last Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Today's Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about me or our programs? Please include the person who referred you if applicable.
Preferred Method of Initial Contact
Text
Phone Call
Email
Social Media DM
Areas of Interest and Current Level of Motivation...
Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc) (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?
Getting Healthy!
This is what we’re here for, right? ☺️
On a scale of 1-10 how serious are you about getting healthy?
1
2
3
4
5
6
7
8
9
10 (I'm ready now, call me and stop playing)
Do you have any of the following?
Diabetes- Type 1
Diabetes- Type 2
High Blood Pressure
Gout
Thyroid
Acid Reflux
Are you taking any medications for:
Diabetes
High Blood Pressure
Gout
Thyroid
High Cholesterol
Lithium*
Coumadin* (Warafin)
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.
Are you taking other medications or have other medical conditions that could influence which program we choose?
What time do you typically wake up?
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor.
**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
Sleep
How many hours of sleep do you typically get?
What time do you go to bed?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Energy Drinks
If so, how often and how much on average?
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
Please Select
Sedentary
On your feet
Active
Describe some things that you can't do, that you wish you could?
Mind
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Describe your level of enjoyment with your work.
If you needed an additional $500 a month, what would that take at your current employment?
When and where was your last vacation?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
When you eat out, which of the following do you grab?
Sit down restaurant
Fast Food
Gas Station or Vending Machine
Coffee Shops (You know what I'm talking about)
Weight
Current Weight: (if you want to share)
Height:
Goal weight or size:
In a perfect world, if you could not fail, how many pounds would you want to lose?
What has been the most difficult thing about losing weight in the past?
Surroundings
How healthy would you rate your surroundings? (on a scale of 1-10)
Do you have healthy & active friends, supportive family, keep junk food in the house, etc
Is there anyone in your life who would like to get healthy with you?
Please provide me with a few times you will be available to chat within the next 24-48 hours.
Other information to share.
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