Health Assessment Form

Health Assessment

Whether you want to lose weight, come off meds or improve your health, we can help!
Your Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
E-mail*
example@example.com
How did you hear about us or who referred you?
What is your age range?*

l8-3031-4950-6465+
Gender*

MaleFemale
What would you like to accomplish with your health? What is your main motivation for wanting to make changes? *
Check all that apply to you*

I have type 1 diabetesI have type 2 diabetesI have high blood pressureI have GoutI take thyroid medsI take Coumadin (Warfarin)I take LithiumI am pregnantI am a nursing motherNone of the above
Do you have any of the following allergies:*

GlutenSoyEggsDairyNutsVegetarianVeganNone of the above
Current Weight & Height*
Desired Weight*
When was the last time you were at your healthy BMI? You want to be in the green.*
How many hours of sleep do you get in a typical night?*

8 or more6-7less than 6
How many days a week do you exercise?*

None1-33 or more
How many 8oz glasses of water do you drink per day?*
How many times do you eat out per week? (Including Fast Food)*

1-23-4DailyNever
Typically American's spend between $15-$20 a day on food. How much do you believe you spend? *
On a scale of 1-5, how would you rate your current state of mental/emotional well-being?*

1

2

3

4

5

1 is Worst, 5 is Best
On a scale of 1-5, how committed are you to making a change in your health? What is your health worth to you?*

1

2

3

4

5

1 is I doubt myself and don't know if I can, 5 is I'm so ready. Let's do this!!
Are you willing to invest 15 minutes a day to learning new habits that will support lifelong transformation?*

YesMaybeNo
Is there anyone in your life who would like to get healthy with you? Our clients who do this with a partner or friend tend to have better success! If yes, who?*
Are you interested in receiving some information about how you could earn additional income by simply sharing health and hope with others?*

Sure, send me some info!Not at this time, thanks.
What is the best day of the week to contact you to go over your results? (check all that apply)*

MondayTuesdayWednesdayThursdayFridaySaturday
What is the best time of day to contact you?*

MorningAfternoonEvening
What time zone are you in?*

PacificMountainCentralEastern
Are you on Facebook?*

YesNo
Are you familiar with Zoom?*

YesNo
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