Your Health Assessment
Let's figure out where you are and where you want to go in your health.
Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
I would love to hear what you would like to accomplish with your health. What would you say your main goal would be? Weight-loss, improved sleep, better response to stress, etc.
Why now? What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
Can you tell me about a time in your life when you were healthier? What has changed between then and now?
Tell me about your health: Do you have any allergies or medical conditions that could influence which plan we choose?
Reminder: We recommend that Clients contact their healthcare provider before starting and throughout their weight loss journey. Do you have a primary care physician?
Yes
Haven't been in awhile
Not at this time
Are you Pregnant?
NO
Yes
Are you currently being treated for or taking meds for:
High Blood Pressure
Diabetes
Diabetes Type I
High Blood Pressure
Diabetes Type II
Gout
Thyroid
Gluten Intolerance
Coumadin (Warfarin)
Food Allergies
Lithium
Other
STEP 2: TELL ME ABOUT YOUR DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
WEIGHT MANAGEMENT
Age
Current Weight
Desired Weight
Current BMI (if known)
Have you tried to lose weight in the past?
Movement & Activity
How would you describe the regular quantity and quality of the activity do each week?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
What types of physical activity do you enjoy?
MIND
On a scale of 1-10, how fulfilled are you in life/career/family?
On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do for work?
DAILY FOOD & HYDRATION
How many meals and snacks do you eat per day?
When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
Do you drink other beverages? Coffee, soda, alcohol, tea, etc. If so, how often and how much?
YOUR SURROUNDINGS
On a scale of 1-10, how conducive are your surroundings to support your health journey? Does family, keep junk food in the house, etc
Is there anyone in your life who would like to get healthy with you?
Is there anything else you think I should know about your health?
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