LIVE: FITT Challenge Health Assessment Form

1
THE INFORMATION DERIVED FROM THIS CONSULTATION IS STRICTLY CONFIDENTIAL.

IMPORTANT: This health and nutrition evaluation is intended for educational purposes only, to assist the individual in learning how to preserve their own health. It is not the intention of this evaluation to diagnose or to prescribe any medication, treatment, or modality for any physical or mental disorder, disease, ailment, complaint, or anomaly. Therefore, any use of the information obtained from this health and nutritional evaluation is at the sole discretion of, and in response to the direct request made by the individual whose name is signed on this form.

This consultation form uses the principles derived from the FITT Challenge. Each Lifestyle Consultant works as an independent consultant and their opinions or advice does not necessarily reflect those of the aforementioned wellness program.
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Full Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
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Date of Birth* This field is required.
Date
Year
Month
Day
5
Phone Number* This field is required.
6
What is your Gender?* This field is required.
Male
Female
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Ethnicity:
8
Marital Status
Single
Married
Divorced
Seperated
Widowed
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Religious Affiliation (Optional)
10
Emergency ContactPhone
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Health Information
Age
Height
Weight
Blood Pressure
Pulse
Glucose
Cholesterol
HDL/LDL
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Additional Health Information
Huge
Large
Normal
Small
Ok
Ok
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Date of last doctor’s visit:
14
Physician’s Name:
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Health Conditions* This field is required.
1 = Never
2 = Occasionally
3 = Sometimes
4 = Most of the time
5 = Always
Absent Minded
Row 0, Column 0
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Acne
Row 1, Column 0
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Allergies
Row 2, Column 0
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Anemia
Row 3, Column 0
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Alcoholism
Row 4, Column 0
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Arthritis
Row 5, Column 0
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Asthma
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Cancer
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Chest Pains
Row 8, Column 0
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Constipation
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Crave sweets/coffee
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Depression
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Diabetes
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Diarrhea
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Difficulty Breathing
Row 14, Column 0
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Digestive Disorders
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Dizziness
Row 16, Column 0
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Eat When Depressed
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Eat When Nervous
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Eczema
Row 19, Column 0
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Emphysema
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Excessive Hunger
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Excessive Worry
Row 22, Column 0
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Fatigue
Row 23, Column 0
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Foul Smelling Urine
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Frequent Colds
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Frequent Kidney Infections
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Frequent Urination
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Gallstones
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Hay fever
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Headaches
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Heart Disease
Row 31, Column 0
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High Blood Pressure
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Indigestion/Heartburn
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Insomnia
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Kidney Stones
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Mental Disorder
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Nervous Disorder
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Prostate Trouble
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Sinusitis
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Skin Problems
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Sluggish in the A.M.
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Swollen Glands
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Ulcers/Colitis
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Wake Up Tired
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Weight Problem
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Absent Minded
Acne
Allergies
Anemia
Alcoholism
Arthritis
Asthma
Cancer
Chest Pains
Constipation
Crave sweets/coffee
Depression
Diabetes
Diarrhea
Difficulty Breathing
Digestive Disorders
Dizziness
Eat When Depressed
Eat When Nervous
Eczema
Emphysema
Excessive Hunger
Excessive Worry
Fatigue
Foul Smelling Urine
Frequent Colds
Frequent Kidney Infections
Frequent Urination
Gallstones
Hay fever
Headaches
Heart Disease
High Blood Pressure
Indigestion/Heartburn
Insomnia
Kidney Stones
Mental Disorder
Nervous Disorder
Prostate Trouble
Sinusitis
Skin Problems
Sluggish in the A.M.
Swollen Glands
Ulcers/Colitis
Wake Up Tired
Weight Problem
1 = Never
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2 = Occasionally
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3 = Sometimes
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4 = Most of the time
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5 = Always
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1 = Never
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2 = Occasionally
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3 = Sometimes
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4 = Most of the time
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5 = Always
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1 = Never
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2 = Occasionally
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3 = Sometimes
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4 = Most of the time
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5 = Always
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1 = Never
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2 = Occasionally
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3 = Sometimes
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4 = Most of the time
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5 = Always
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1 = Never
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2 = Occasionally
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3 = Sometimes
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4 = Most of the time
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5 = Always
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1 = Never
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2 = Occasionally
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3 = Sometimes
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4 = Most of the time
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5 = Always
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1 = Never
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2 = Occasionally
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3 = Sometimes
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4 = Most of the time
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5 = Always
Row 6, Column 4
1 = Never
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2 = Occasionally
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3 = Sometimes
Row 7, Column 2
4 = Most of the time
Row 7, Column 3
5 = Always
Row 7, Column 4
1 = Never
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2 = Occasionally
Row 8, Column 1
3 = Sometimes
Row 8, Column 2
4 = Most of the time
Row 8, Column 3
5 = Always
Row 8, Column 4
1 = Never
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2 = Occasionally
Row 9, Column 1
3 = Sometimes
Row 9, Column 2
4 = Most of the time
Row 9, Column 3
5 = Always
Row 9, Column 4
1 = Never
Row 10, Column 0
2 = Occasionally
Row 10, Column 1
3 = Sometimes
Row 10, Column 2
4 = Most of the time
Row 10, Column 3
5 = Always
Row 10, Column 4
1 = Never
Row 11, Column 0
2 = Occasionally
Row 11, Column 1
3 = Sometimes
Row 11, Column 2
4 = Most of the time
Row 11, Column 3
5 = Always
Row 11, Column 4
1 = Never
Row 12, Column 0
2 = Occasionally
Row 12, Column 1
3 = Sometimes
Row 12, Column 2
4 = Most of the time
Row 12, Column 3
5 = Always
Row 12, Column 4
1 = Never
Row 13, Column 0
2 = Occasionally
Row 13, Column 1
3 = Sometimes
Row 13, Column 2
4 = Most of the time
Row 13, Column 3
5 = Always
Row 13, Column 4
1 = Never
Row 14, Column 0
2 = Occasionally
Row 14, Column 1
3 = Sometimes
Row 14, Column 2
4 = Most of the time
Row 14, Column 3
5 = Always
Row 14, Column 4
1 = Never
Row 15, Column 0
2 = Occasionally
Row 15, Column 1
3 = Sometimes
Row 15, Column 2
4 = Most of the time
Row 15, Column 3
5 = Always
Row 15, Column 4
1 = Never
Row 16, Column 0
2 = Occasionally
Row 16, Column 1
3 = Sometimes
Row 16, Column 2
4 = Most of the time
Row 16, Column 3
5 = Always
Row 16, Column 4
1 = Never
Row 17, Column 0
2 = Occasionally
Row 17, Column 1
3 = Sometimes
Row 17, Column 2
4 = Most of the time
Row 17, Column 3
5 = Always
Row 17, Column 4
1 = Never
Row 18, Column 0
2 = Occasionally
Row 18, Column 1
3 = Sometimes
Row 18, Column 2
4 = Most of the time
Row 18, Column 3
5 = Always
Row 18, Column 4
1 = Never
Row 19, Column 0
2 = Occasionally
Row 19, Column 1
3 = Sometimes
Row 19, Column 2
4 = Most of the time
Row 19, Column 3
5 = Always
Row 19, Column 4
1 = Never
Row 20, Column 0
2 = Occasionally
Row 20, Column 1
3 = Sometimes
Row 20, Column 2
4 = Most of the time
Row 20, Column 3
5 = Always
Row 20, Column 4
1 = Never
Row 21, Column 0
2 = Occasionally
Row 21, Column 1
3 = Sometimes
Row 21, Column 2
4 = Most of the time
Row 21, Column 3
5 = Always
Row 21, Column 4
1 = Never
Row 22, Column 0
2 = Occasionally
Row 22, Column 1
3 = Sometimes
Row 22, Column 2
4 = Most of the time
Row 22, Column 3
5 = Always
Row 22, Column 4
1 = Never
Row 23, Column 0
2 = Occasionally
Row 23, Column 1
3 = Sometimes
Row 23, Column 2
4 = Most of the time
Row 23, Column 3
5 = Always
Row 23, Column 4
1 = Never
Row 24, Column 0
2 = Occasionally
Row 24, Column 1
3 = Sometimes
Row 24, Column 2
4 = Most of the time
Row 24, Column 3
5 = Always
Row 24, Column 4
1 = Never
Row 25, Column 0
2 = Occasionally
Row 25, Column 1
3 = Sometimes
Row 25, Column 2
4 = Most of the time
Row 25, Column 3
5 = Always
Row 25, Column 4
1 = Never
Row 26, Column 0
2 = Occasionally
Row 26, Column 1
3 = Sometimes
Row 26, Column 2
4 = Most of the time
Row 26, Column 3
5 = Always
Row 26, Column 4
1 = Never
Row 27, Column 0
2 = Occasionally
Row 27, Column 1
3 = Sometimes
Row 27, Column 2
4 = Most of the time
Row 27, Column 3
5 = Always
Row 27, Column 4
1 = Never
Row 28, Column 0
2 = Occasionally
Row 28, Column 1
3 = Sometimes
Row 28, Column 2
4 = Most of the time
Row 28, Column 3
5 = Always
Row 28, Column 4
1 = Never
Row 29, Column 0
2 = Occasionally
Row 29, Column 1
3 = Sometimes
Row 29, Column 2
4 = Most of the time
Row 29, Column 3
5 = Always
Row 29, Column 4
1 = Never
Row 30, Column 0
2 = Occasionally
Row 30, Column 1
3 = Sometimes
Row 30, Column 2
4 = Most of the time
Row 30, Column 3
5 = Always
Row 30, Column 4
1 = Never
Row 31, Column 0
2 = Occasionally
Row 31, Column 1
3 = Sometimes
Row 31, Column 2
4 = Most of the time
Row 31, Column 3
5 = Always
Row 31, Column 4
1 = Never
Row 32, Column 0
2 = Occasionally
Row 32, Column 1
3 = Sometimes
Row 32, Column 2
4 = Most of the time
Row 32, Column 3
5 = Always
Row 32, Column 4
1 = Never
Row 33, Column 0
2 = Occasionally
Row 33, Column 1
3 = Sometimes
Row 33, Column 2
4 = Most of the time
Row 33, Column 3
5 = Always
Row 33, Column 4
1 = Never
Row 34, Column 0
2 = Occasionally
Row 34, Column 1
3 = Sometimes
Row 34, Column 2
4 = Most of the time
Row 34, Column 3
5 = Always
Row 34, Column 4
1 = Never
Row 35, Column 0
2 = Occasionally
Row 35, Column 1
3 = Sometimes
Row 35, Column 2
4 = Most of the time
Row 35, Column 3
5 = Always
Row 35, Column 4
1 = Never
Row 36, Column 0
2 = Occasionally
Row 36, Column 1
3 = Sometimes
Row 36, Column 2
4 = Most of the time
Row 36, Column 3
5 = Always
Row 36, Column 4
1 = Never
Row 37, Column 0
2 = Occasionally
Row 37, Column 1
3 = Sometimes
Row 37, Column 2
4 = Most of the time
Row 37, Column 3
5 = Always
Row 37, Column 4
1 = Never
Row 38, Column 0
2 = Occasionally
Row 38, Column 1
3 = Sometimes
Row 38, Column 2
4 = Most of the time
Row 38, Column 3
5 = Always
Row 38, Column 4
1 = Never
Row 39, Column 0
2 = Occasionally
Row 39, Column 1
3 = Sometimes
Row 39, Column 2
4 = Most of the time
Row 39, Column 3
5 = Always
Row 39, Column 4
1 = Never
Row 40, Column 0
2 = Occasionally
Row 40, Column 1
3 = Sometimes
Row 40, Column 2
4 = Most of the time
Row 40, Column 3
5 = Always
Row 40, Column 4
1 = Never
Row 41, Column 0
2 = Occasionally
Row 41, Column 1
3 = Sometimes
Row 41, Column 2
4 = Most of the time
Row 41, Column 3
5 = Always
Row 41, Column 4
1 = Never
Row 42, Column 0
2 = Occasionally
Row 42, Column 1
3 = Sometimes
Row 42, Column 2
4 = Most of the time
Row 42, Column 3
5 = Always
Row 42, Column 4
1 = Never
Row 43, Column 0
2 = Occasionally
Row 43, Column 1
3 = Sometimes
Row 43, Column 2
4 = Most of the time
Row 43, Column 3
5 = Always
Row 43, Column 4
1 = Never
Row 44, Column 0
2 = Occasionally
Row 44, Column 1
3 = Sometimes
Row 44, Column 2
4 = Most of the time
Row 44, Column 3
5 = Always
Row 44, Column 4
1 = Never
Row 45, Column 0
2 = Occasionally
Row 45, Column 1
3 = Sometimes
Row 45, Column 2
4 = Most of the time
Row 45, Column 3
5 = Always
Row 45, Column 4
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What specific concerns or conditions would you like this consultation to address?
17
List any medications you are currently taking
18
Do you have any medication allergies?* This field is required.
Yes
No
Not Sure
19
List all minerals, vitamins, and supplements you are taking now. Include the amount and how often.
20
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
21
Do you use or do you have history of using tobacco?
YESNO
22
Food Allergies
23
Do you have any present stressors in your life?
YESNO
24
What is your occupation?
25
What hours do you work?
26
Recreational activities enjoyed:
27
Hours per week viewing TV:
28
Do you often feel guilty about past mistakes?
YESNO
29
Do you worry about the future?
YESNO
30
Is there anyone in your life that is upset or angry with you?
YESNO
31
On a scale of 1 to 10, rate your stress level
32
Check the following categories which cause you stress:
Financial
Job
Getting along with people
Family
Not happy with myself
Health
33
How important is your spiritual life to your overall health?
Not important
Somewhat important
Very Important
34
What time do you go to bed?
35
Do you have a hard time falling asleep?* This field is required.
YESNO
36
If so, what factors affect your sleep?* This field is required.
37
What time do you wake up?
38
How many hours per night of sleep do you get on average?
39
What time is your last meal of the day?
40
Do you snack just before bedtime?
YESNO
41
Do you have trouble sleeping?
YESNO
42
How much time do you spend getting sunshine?* This field is required.
43
Do you often get sunburned?
YESNO
44
Are you afraid of getting skin cancer?
YESNO
45
Have you ever checked your Vitamin D levels? Yes / No If so, what was your number in the results?
46
What foods do you frequently eat?
47
Do you eat meat?
YESNO
48
If so: Red Meat? Chicken/Fish? Seafood?
49
Do you eat dairy products?
YESNO
50
Do you eat desserts, candy or other sweets regularly?
YESNO
51
Do you eat Breakfast?* This field is required.
YESNO
52
If so what do you eat for breakfast?
53
What are your meal times?
54
Do you eat an evening meal?
YESNO
55
If so how late do you eat it?
56
Favorite Food(s) & Meal(s):
57
How often do you exercise?* This field is required.
5 or more times a week
2 – 4 times a week
Less than 2 times a week
Never
58
Describe the exercise:
59
How do you feel after you exercise?
60
How many glasses of water do you drink each day?
None
1 – 3
4 – 6
7 or more
61
What type? (spring, filtered, distilled, tap):
62
BEVERAGE
Soda
Coffee
Tea
Fruit Juice
Sports Drinks
Milk
Other
63
Do you feel like you urinate too much? Not enough?
64
Do you ingest caffeine in any form?
YESNO
65
If yes, for how many years?
66
If no, have you ever ingested caffeine on a regular basis?
67
Do you smoke or chew tobacco?
YESNO
68
If yes, for how many years?
69
If no, have you used tobacco in the past?
70
Do you drink alcohol? If so, what kind(s)?
71
Do you ever volunteer your time?
72
Would you consider yourself more self-focused or others-centered?
73
Would friends and family agree with your self assessment?
YESNO
74
Are there any particular “causes” that interest you? i.e., feeding the homeless, helping the poor, mentoring young people, caring for orphans, spending time with seniors?
75
Do you work in an office building/hospital/school or at home?
76
How many hours daily do you spend out of doors?
77
Do you sleep with your windows open or closed?
78
Are you able to breathe fresh air while you are working?
YESNO
79
Is the building where you work a non-smoking facility
YESNO
80
How much time do you spend reading something each day?
81
Do you like to read?
YESNO
82
What is your favorite of the following? Reading books, watching TV/videos or listening to music, time in nature in the open air.
83
What type of subjects interest you? Fiction? History? How to? Comedy? Non-fiction?
84
When out in nature, what do you notice most? How does it affect you?
85
How would you rate your health?
Excellent
Good
Fair
Poor
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Availability for Health Coaching SessionPlease select ALL the days and times you are available for coaching sessions
Morning
Noon
Evening
Sunday
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Wednesday
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Thursday
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Monday
Tuesday
Wednesday
Thursday
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PLEASE REMEMBER TO SIGN AND DATE THE FRONT OF THIS QUESTIONNAIRE! WE CANNOT RESPOND WITHOUT YOUR SIGNATURE AND DATE: BY SIGNING YOU ARE SHOWING THAT YOU UNDERSTAND THAT THIS QUESTIONNAIRE AND THE EDUCATIONAL INFORMATION GIVEN IN THIS CONSULTATION IS SOLELY FOR EDUCATIONAL PURPOSES ONLY AND IS NOT INTENDED TO DIAGNOSE OR TREAT ANY DISEASE, AILMENT OR ABNORMALITY.
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