Health Assessment with Bette

Health Assessment

Transform to Thrive with Bette Haskin, Certified Health Coach
Full Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Full Address
How did you hear about the program?
If you were referred, name of the person who referred you.
Preferred Method of Contact

TextCall
Awaken

discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)
Describe where you would like to be in your Health...
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)?
Medical
Pregnant

YesNo
Nursing

YesNo
Age of Baby
Medications

DiabetesHigh Blood PreassureLithium*Thyroid**Coumadin (Warfarin)***Other
Conditions

High Blood PressureDiabetes Type IDiabetes Type IIGoutGluten Intolerance or SensitivitySoy Allergy or IntoleranceFood AllergiesOther
Any other allergies or conditions which may influence which program we choose?
*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 typically go to bed?
What time do you typically wake up?
How is the quality of your sleep?
Do you wake up feeling rested?
Motion
On a scale of 1-10, what is your energy level throughout the day?
How many days a week do you exercise?
About how many hours a day do you sit or lay down?
What types of physical activity do you enjoy? Are there things you can't do that you'd like to be able to do?
How would you describe the quantity and quality of the activity you do each week?
Stress
On a scale from 1-10, how much do you worry?
What do you do for work?
On a scale from 1-10, how much do you enjoy what you do?
On a scale from 1-10, how fulfilled are you?
What area of your life tends to be the biggest stress for you?
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 between meals?
How much do you eat out each week?
Where do you eat out?
Hydration
How much water do you drink per day?
How much Coffee?
How much Soda?
How much Tea?
How much Alcohol?
Weight
Current weight
Goal weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
Surroundings
On a scale from 1-10, how healthy would you rate your surroundings?
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?
Is there anything else you think I should know about your health?
Should be Empty:

Health Assessment

Awaken

Medical

Sleep

Motion

Stress

Eating Habits

Hydration

Weight

Surroundings