Health Assessment

Health Assessment

It's great speaking with you today and I'm excited to see if I can assist you with your goals! Before we can determine if one of our Programs is right for you, let's answer a few questions about you, and your health goals.
Personal Information:
Full Name *

First Name Middle Name Last Name
Age *
Sex *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
E-mail *
example@example.com
STEP 01: AWAKEN
What you would like to accomplish with your health. (Weight loss, improved sleep, better response to stress, etc.)
What is your main motivation for wanting to make changes to your health? (Relationships, activities, how will you feel, etc.)
Tell me about a time in your life when you were healthier? What has changed between then and now?
Tell me about your health: *Any allergies/medical conditions that would influence which Program we choose?
Are you pregnant?

Yes No
Are you Nursing?

Yes No
Are you taking any medications for:

Diabetes *Lithium **High Blood Pressure ***Coumadin (Warfarin) Other
Do you have the following:

High Blood Pressure Diabetes I Diabetes II Gout Gluten Intolerance/Sensitivity Soy Allergy/Intolerance Food Allergies Other
*Lithium: Healthcare provider may wish to adjust frequency of lab work for client and monitor **Thyroid Medications: 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.
STEP 02: DAILY ROUTINE & HABITS
SLEEP & ENERGY
I sleepblanks hours per night. The quality of my sleep is blank . On a scale of 1-10, what is your energy level throughout the day?
Describe the quantity/quality of activity I do each week. blanks
blanks of hours I spend sitting.
blanks days per week I exercise.
My favorite activities include blanks
MIND
On a scale of 1-10, how fulfilled are you? blanks
On a scale of 1-10, how much do you worry? blanks
What area of your life is your biggest stress? blanks blank
What do you do for work? blanks blank
On a scale of 1-10, how much do you enjoy what you do? blanks
FOOD & HYDRATION
How many meals/snacks do you eat per day?
When do you eat your first meal of the day?
How many times/week do you eat out? And where?
How many glasses of water do you drink daily?
Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
How often? And how much?
WEIGHT MANAGEMENT
How tall are you?
What is your current weight?
What would you consider a healthy weight for you?
Have you tried to lose weight in the past?

Yes No
What has been difficult for you about losing/maintaining weight?
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? blanks
Do you have healthy and active friends, family, etc?
Do you have supportive friends, family, etc?
Is there anyone in your life who would like to get healthy with you?
Awesome Sauce!

Now that the tough part is over, and while I look over your answers, the next step for you is to schedule a time we can connect for - (pssst... this is my favorite part) - a quick chat about getting you to a healthier, happier YOU!
Appointment *
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Health Assessment

Awesome Sauce!