FREE HEALTH ASSESSMENT

Name

Date*

Today's date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone*

Email*

example@example.com

Date of Birth

Date

How did you hear about our program?*

Preferred Method Of Contact*

TextCallemailOther

Awaken...Discover where you are and where you want to be!

Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)*

How much water do you drink each day?*

How much coffee, how do you drink it?*

How much soda or tea?*

How much alcohol do you consume and how often?*

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

How would you rate your energy level on a scale from 1-10?*

How many times a week do you exercise and what do you like to do?*

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

Are there things you can’t do that you would like to be able to do once you get healthy?*

What do you do for work?*

How much do you enjoy what you do?*

Are there other stressors in your life?*

STRESS(On a scale of 1-10)*

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)?*

Check all that apply

Diabetes Type 1Diabetes Type 2High Blood PressureGout

Are you taking any medications for:

Are you taking other medications or do you have other medical conditions that could influence which program we choose

Medical *We recommend that clients contact their healthcare provider before starting and throughout their weight loss journey.

*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.

Are you Pregnant ?

YesNo

Are you Nursing?

YesNo

If yes, how old is your baby?

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?*

Are there any food or other allergies that I should be aware of*

How many times a week do you eat out? This includes restaurants, fast food, vending machines, convience stores*

Where*

Current Weight

Goal Weight*

Height*

Have you tried to lose weight before?*

What has been most difficult about losing/maintaining weight in the past?*

How many hours of sleep do you typically get?*

SURROUNDINGS(On a scale of 1-10)

How healthy would you rate your surroundings? Meaning like support at home, at work, temptations at home, support with family and friends, etc. On a scale of 1-10.

Do you have healthy & active friends, supportive family, keep junk food in the house, etc

What time do you typically go to bed?*

Wake up?*

Quality of Sleep? Do you wake up feeling rested?*

Is there anyone in your life who would like to get healthy with you?*