HEALTH ASSESSMENT

HEALTH ASSESSMENT

Health Coach: Stephanie Jackson
Name
Email
example@example.com
Today's Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Phone
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
How did you hear about our program?
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)
Describe where you would like to be in your health.
Please describe WHY you are interested in getting healthy. (What is your main Motivation Relationships, activities, how you will feel, etc)
When was the last time you remember feeling your best in your health or being at your ideal weight or size(if that's part of your goal)?
Medical

We recommend that clients contact their healthcare provider before starting and throughout the weight loss journey.
Are you pregnant?
Are you Nursing?
If yes, how old is your baby?
Do you have any of the following (check all that apply)
Are there any food or other allergies that I should be aware of?
Are you taking any medications for:
Are you taking other medications or do you have other medical conditions that could influence the program we choose?
* 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

***Cournadin (Warfarin): The healthcare provider may wish to review food cholces, conduct lab work and/or adjust medication
DAILY ROUTINE & HABITS

Research shows that there are 7 significant factors that contribute to overall physical health.
Hydration...
How much water do you drink each day?
How much coffee?
How much soda?
How much tea (black or green)?
How much alcohol?
Motion...
How would you rate your energy level? (on a scale of 1-10)
What physical activities do you participate in?
How many times a week do you exercise?
Are there things you can't do that you would like to be able to?
Stress...
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
Eating Habits...
How many meals per day do you eat?
When do you eat your first meal?
When do you eat last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
When you do eat out where do you typically go?
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?
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 the quality of sleep?
Do you wake up feeling rested?
Surroundings...
How healthy would you rate your surroundings? (on a scale of 1-10)
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?
Should be Empty:

HEALTH ASSESSMENT

Awaken...

Medical

DAILY ROUTINE & HABITS

Hydration...

Motion...

Stress...

Eating Habits...

Weight...

Sleep...

Surroundings...