HEALTH ASSESSMENT - Bercier Team

HEALTH ASSESSMENT
Name *
Email *
example@example.com
Date *

Month Day Year
Today's Date
City *
Phone Number *
Date of Birth

Month Day Year
Date
How did you hear about our program?
If you were referred, name of person who referred you.
Preferred Method Of Contact *

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

0/330
Describe where you would like to be in your Health... *

0/330
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

Yes No
Are You Nursing

Yes No
If yes, how old is your baby
Do you have the following *

Diabetes - Type 1 Diabetes - Type 2 High Blood Pressure Gout None of the above
Are there any food or other allergies that I should be aware of? *

0/160
Are you taking any medications for:

Diabetes High Blood Pressure High Cholesterol Thyroid** Lithium* Coumadin (Warfarin)***
Are you taking other medications or have other medical conditions that could influence which program we choose? *

0/185
*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
Do you wake up feeling rested? *
HYDRATION
How much water do you drink each day? *
Any Regular Soda? (if yes, how much?) *
How much Alcohol?

0/50
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?
Do you snack between meals?
What kind of snacks?
How many times a week do you dine out or get fast food? *
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? *

0/200
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?
Do you have a Health Savings Account (HSA) with your insurance? *

Yes No Unsure
Should be Empty:

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