Health Assessment Form
This form should take around 5-10 minutes to complete.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What would you like to accomplish with your health (weight loss, improved sleep, better response to stress, etc.)?
What is your primary motivation for wanting to make changes to your health (Relationships, activities, how you will feel, etc.)?
Do you have any of the following allergies?
Gluten
Soy
Eggs
Dairy
None
Vegetarian
Other
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Personal Information
Desired Weight
Share a bit about your life... About your family? Are you currently working? Favorite hobbies? Etc.
Who in your life would you like to get healthy with you?
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Healthy Sleep
How many hours of sleep do you get in a typical night?
8 or more
6-7
Less than 6
How would you describe your quality of sleep?
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Healthy Mind
How many days a week do you exercise?
Please Select
1
2
3
4
5
6
7
What type of physical activity do you enjoy?
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Healthy Mind
On a scale of 1 to 10 how fulfilled are you? (1 = not fulfilled; 10 very fulfilled)
What area o your life tends to be the biggest stress for you?
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Food and Hydration Habits
How many meals do you eat per day?
Please Select
1
2
3
4+
How many snacks do you eat per day?
Please Select
No Snacking
1
2
3
I tend to graze all day
How soon after waking do you eat something?
Please Select
30 minutes
1 hour
More than 1 hour
Lunch time or longer
How many ounces of water do you drink per day?
0
16
32
48
64
More than 64 oz
How many times do you eat out per week (including fast food)?
Never
1-2
3-5
Daily
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Healthy Finances
Financially speaking, I am
Very comfortable
Have enough for my needs
Feel strapped
Concerned about making ends meet
Choose not to answer
What do you currently do for a living?
My current employment is...
Very fulfilling
Pays the bills, but I don't love it
Can't quite make ends meet
Other
Are you interested in learning more about helping others with their health while also earning a great income?
Yes, very!
I am curious
Maybe
Concerned about making ends meet
Not at this time
Submit
Should be Empty: