Health Inquiry

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

How did you hear about us?

Other

Please fill out the following document to give me a clear picture on where you are with your health & habits, and where you would like to go with them.

If failure wasn't an option, what is a dream health goal you have for yourself?

When you reach that goal, what things will you start doing that you might not be doing now (what would be more enjoyable to do, such as swimming, taking photos, being active)?

Now that you're at this point, how do you imagine what your overall emotional health will look like?

Tell me about a time in your life when you felt good? What has changed between then and now?

How many hours of sleep do you get, do you feel rested?

Scale of 1-10, what are your energy levels? (10 being high)

Do you have an exercise routine?

On a scale of 1-10 what are your stress levels? (10 being high)

How many oz of water do you drink? Do you drink anything else?

How many times a day do you eat?

Do you snack?

Do you take any medications and/or have any health concerns?

Did someone refer you?

Tell us who referred you

Rows	Full Name	Contact Number
1

When is the best time for me to contact you to give you more information about our health plan and see if it is a right fit for you?

Starting Weight

Desired weight

Health Inquiry: