Form

FREE HEALTH ASSESSMENT
Name

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
How did you hear about our program?
Preferred Method Of Contact

TextCallEmailOther
Describe where you are in your health now....(weight, sleep, stress, energy level, ect)
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 current energy level on a scale f 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 motivation? Relationships, activities, how you want to feel, ect.)
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:

DiabetesHigh blood pressureLithiumThryoidHigh Cholesterol
Are you taking other medications or do you have any 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 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
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 machine, convenience store.
Current Weight?
Goal Weight?
Height?
What has been most difficult about losing/maintaining weight in the past?
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 also like to get healthy with you?
Should be Empty:

FREE HEALTH ASSESSMENT