HEALTH ASSESSMENT

Do you want to improve your health by losing weight, increasing your energy, etc.? If so, please fill out this confidential form and it will be sent directly to my Inbox.
HEALTH ASSESSMENT

Carolyn Clarke
Name*
Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address*
City*
State*
Two Letter Abbreviation
Zip Code*
Phone Number*
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

TextCallEmail
Awaken...Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)*

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Describe where you would like to be in your Health...*

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Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)*

0/330
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)?*

0/330
Medical
Are You Pregnant

YesNo
Are You Nursing

YesNo
If yes, how old is your baby
Do you have the following

Diabetes - Type 1Diabetes - Type 2High Blood PressureGout
Are there any food or other allergies that I should be aware of?

0/160
Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroid**Lithium*Coumadin (Warfarin)***
Are you taking other medications or have other medical conditions that could influence which program we choose?*

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*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?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much Coffee?
How much Soda?
How much Tea?
How much Alcohol?

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MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
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 your last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Where?
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?*

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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: