HEALTH ASSESSMENT - Get Healthy with Collins

HEALTH... It's more than just the number on the scale.

Let's see what those goals are!
First and Last Name
Email
example@example.com
Date

MonthDayYear
Today's Date
Address
City
State
Two Letter Abreviation
Zip Code
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
How did you hear about our program?
If you were referred, name of person who referred you.
Preferred Method Of Contact
Awaken...Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)

0/330
Describe where you would like to be in your Health... What does that look like?

0/330
Please describe WHY you are interested in getting healthy: Besides wanting to look and feel better, please list 3 other main motivations or goals for wanting to take back your health. (What is your main Motivation...relationships, activities, how you feel, how you like what you see in the mirror/pictures, clothes you buy... etc.)

0/330
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)? What do you miss the most about that season of life?

0/330
Medical
Are You Pregnant
Are You Nursing
If yes, how old is your baby
Do you have the following
Are there any food or other allergies that I should be aware of?

0/160
Are you taking any medications for:
Are you taking other medications or have other medical conditions that could influence which program we choose (Kidney, bowel, medically recommended food restrictions...etc.)?

0/185
*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 your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much Coffee?
How much Soda?
How much Tea?
How much Alcohol?

0/50
MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
STRESS
How would you rate your stress level? (on a scale of 1 = no stress to 10 = VERY stressed)
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
EATING HABITS

Walk me through the average day.
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?
What kind of snacks?
How many times a week do you eat out?
Where do you eat out/order from?
Average American spends between $15-$25 a day on food/nutrition. How much do you think you spend on everything you consume each day (food, drinks, drive throughs, supplements, ordering out.... etc.)?

Other
WEIGHT
Walk me through a typical day for you when it comes to your eating habits.
Current Weight
Goal Weight (Throw fear out the window for this answer and dream big!)
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?

0/200
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?
Thank you for sharing this with me! Once you hit submit it will go straight to my mailbox so I can review it. Shoot me a quick text message to let me know you have completed the form and are ready to talk. I will reach back out with a time to connect.
Talk to you soon!
Michelle Collins
Should be Empty:

HEALTH... It's more than just the number on the scale.

Thank you for sharing this with me! Once you hit submit it will go straight to my mailbox so I can review it. Shoot me a quick text message to let me know you have completed the form and are ready to talk. I will reach back out with a time to connect.

Talk to you soon!

Michelle Collins