Name
*
Date
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone
*
Email
*
example@example.com
Date of Birth
/
Month
/
Day
Year
Date
What would you like to accomplish with your health? (Weight loss, improved sleep, better response to stress, etc)
*
0/330
What is your main motivation for wanting to make changes to your health?(Relationships, activities, how you will feel, etc)
*
0/330
Can you tell me about a time in your life when you were healthier? What has changed between then and now?
*
0/330
Medical
Tell me about your health: Do you have any medical conditions that could influence which Program we choose?*
*
0/330
Are you Pregnant
Yes
No
Are you Nursing
Yes
No
If yes, how old is your baby?
Are you taking any medications for:
Diabetes
High Blood Pressure
Lithium(1)
Thyroid(2)
Coumadin/Warfarin(3)
High Cholesterol
Other Medications
What other medications are you taking?
¹Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor²Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.³Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication
Do you have the following:
Diabetes Type 1
Diabetes Type 2
High Blood Pressure
Gout
Food or Other Allergies
What food or other allergies do you have?
DAILY ROUTINE & HABITS
How many hours of sleep do you typically get?
What time do you typically go to bed?
What time do you typically wake up?
Quality of Sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much of other beverages?
Coffee
Soda
Tea
Alcohol
MOTION
How would you rate your energy level? (On a scale of 1-10 with 1 being low energy and 10 being high energy)
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 do?
STRESS
How would you rate your stress level? (On a scale of 1 to 10 with 1 being low stress and 10 being high stress)
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?
What restaurants do you eat at?
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?
*
0/330
SURROUNDINGS
How healthy would you rate your surroundings? (On a scale of 1-10 with 1 being poor surroundings and 10 being great surroundings)
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?
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