Total Health - Health Survey

Health Survey

Jennifer Tavormina - Total Health
Date *

Month Day Year
Date
Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Age *
Preferred Method of Contact *

Call Email Text
Medical
Do you have any of the following:

High Blood Pressure Diabetes Type 1 Diabetes Type 2 Gout
Are you taking any medications for:

Diabetes Thyroid High Blood Pressure High Cholesterol Lithium Coumadin (Warfarin)
Are you pregnant? *

Yes Nursing No
If you are nursing, how old is your baby?
Do you have any food allergies? Please describe. *
Sleep
At what time do you normally go to bed? *
What time do you usually wake up? *
On average, how many hours of sleep do you get? *
How is the quality of your sleep? *
Do you wake up feeling rested? *
Hydration
How much water do you drink in a day? *
How much coffee do you drink in a day? *
How much alcohol do you consume in a week? *
Movement
How many times per week do you exercise? *
What kind of exercise do you participate in? *
Are there things you would like to do that you are currently unable to? *
How would you rate your daily energy level? *

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Stress
What do you do for work? *
Do you enjoy what you do? *
Are there any other stressers in your life? *
Rate your overall stress level *

1

2

3

4

5

6

7

8

9

10

1 is Low Stress, 10 is High Stress
Eating Habits
When do you eat your first meal? *
When do you eat your last meal? *
How many meals per day do you eat? *
Do you snack? If yes, what do you snack on? *
How often do you eat out in a week? *
Where do you typically eat out? *
Weight
Current Weight *
Goal Weight *
Height *
Have you tried to lose weight before? *
If yes, what have you found to be the most difficult part of losing weight in the past?
Thank You! I will reach out to you shortly. You may also email me at jtavormina22@gmail.com
Should be Empty:

Health Survey

Medical

Sleep

Hydration

Movement

Stress

Eating Habits

Weight