Healthy Goals Healthy Living Health Form

Healthy Goals Healthy Living Wellness Survey
Full Name

First NameLast Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Date

MonthDayYear
Date
Age
How did you hear about me or our programs?
What would you like to accomplish most with your health right now (lose weight, metabolic reset, sleep better, less stress, come off medications, more energy, restore memory, improve mindset towards life, etc...)?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
Medical

We will review your medical information when we talk.
Sleep
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
Do you consume any other beverages?
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week and for how many minutes?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How do you prefer to learn?
Should be Empty:

Healthy Goals Healthy Living Wellness Survey

Medical

Sleep

Hydration

Motion

Stress

Eating Habits

Weight