Health Survey

HEALTH SURVEY

Certified Health Coaches Amanda & Marc Avila
Congrats on taking the first step toward Optimal Health!

Please complete and submit this Health Survey. A Health Coach will contact you soon to schedule a free consultation to review your Health Survey and the details of an Optimal Health Plan recommended to help you reach your goals. If you have any questions or are unable to answer any questions, please put "N/A" and we will address them during your consultation. We look forward to hearing about your health goals and helping you plan to reach them!
Name
Email
example@example.com
Date

MonthDayYear
Today's Date
Address
City
State
Two Letter Abbreviation
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 do you wish to improve?

0/330
Please describe WHY you are interested in getting healthy. What is your main motivation?

0/330
When was the last time you remember feeling your best in your health? What has changed between then and now?

0/330
Medical
Are you pregnant?
Are you nursing?
If yes, how old is your baby?
Do you have the following?
Are you taking any medications for:
Please list any medical conditions you have.

0/185
Please list all medications, vitamins and/or supplements you are taking.

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?
Scale of 1 - 10 and 10 being excellent.
Do you wake up feeling rested?
HYDRATION
How many oz of water do you drink each day?
How much coffee per day?
How much soda do you drink per day? Diet or regular?
How often do you drink alcohol?

0/50
MOTION
How would you rate your energy level?
Scale of 1-10 and 10 being excellent.
How many times a week do you exercise? What type and how long?
Example: 7 days- walk dog for 30 min. OR 1 day- yoga for 1 hr.
What physical activities do you participate in?
Example- I lift weights and walk. OR I do not get regular exercise, but I am on my feet walking all day.
Are there things you can't do that you would like to be able to?
STRESS
How would you rate your stress level?
Scale of 1 -10 and 10 being extreme stress.
How much do you enjoy what you do for work?
Scale of 1 - 10 and 10 being "I LOVE WHAT I DO?"
What do you do for work?
Are there other stressors in your life you would like to share as they impact your health?
EATING HABITS
How many meals per day do you eat?
Think about Breakfast, Lunch, & Dinner.
What time do you eat your first meal?
When do you eat your last meal?
Do you snack? How many a day?
What kind of snacks?
How many times a week do you eat out?
Where?
Are there any foods or ingredients that you don't like, avoid or limit?

0/160
WEIGHT
Current Weight
Goal Weight
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?
Think about the people and environments you are in. Scale of 1 -10 and 10 being excellent.
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!

We appreciate you taking the time to provide us with your health history and share your health goals. A health coach will be in touch with you soon to schedule a time review the recommended Optimal Health Plan to help you reach your health goals!
Your Partners in Health,

Amanda & Marc Avila
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HEALTH SURVEY

Congrats on taking the first step toward Optimal Health!

Thank you!

Your Partners in Health,