Language
  • English (US)
  • 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:
  • STEP 01: AWAKEN
  • *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 sleep hours per night. The quality of my sleep is . On a scale of 1-10, what is your energy level throughout the day?      

  • Describe the quantity/quality of activity I do each week.          

  • of hours I spend sitting.

  • days per week I exercise.

  • My favorite activities include          

  • MIND

  • On a scale of 1-10, how fulfilled are you?

  • On a scale of 1-10, how much do you worry?

  • What area of your life is your biggest stress?

  • What do you do for work?

  • On a scale of 1-10, how much do you enjoy what you do?

  • FOOD & HYDRATION

  • WEIGHT MANAGEMENT

  • SURROUNDINGS

  • On a scale of 1-10, how healthy would you rate your surroundings?

  • 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!
  • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free! Create your own Jotform