Health Assessment

Health Assessment

Hentges Health Coaching | Certified Health & Wellness Consultants
We are so happy you are here and ready to reach out about changing your health!

Please fill out as much of the following information under each section as you are comfortable with. Especially the medical questions, this will help me select the best program for you.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date

MonthDayYear
Date
How old are you?
How did you hear about our program?
If you were referred, what is the name of person who referred you
- Describe your Health right now... (weight, sleep, stress, energy, etc.)
- Where would you like to be with your health?
- Start thinking about the main reasons you are wanting to change your health. The biggest part of changing your habits and making healthier choices is going to be driven by those reasons - those are your WHY'S.
  
  Your "Why" is your intrinsic motivation, when everything else fails, this won't.
  
  We will discuss these on the phone in more detail, but, please start thinking about them now.
- Current Weight
- Goal Weight
- Height
- Have you tried to lose weight in the past?
- What has been the most difficult about losing/maintaining weight in the past?
- Are you Pregnant or Nursing?
- If you are nursing, how old is your baby?
- Do you have any of the following? Or are you taking medications in conjuction with these?
  - Diabetes Type 1
  - Diabetes Type 2
  - High Blood Pressure
  - Gout
  - Soy Allergy or Intolerance
  - Gluten Intolerance or Sensitivity
  - Thyroid disease**
  - Lithium*
  - Coumadin (Warfarin***)
  Please specify/expand below:
  
  type n/a if none apply to you
- Do you have any food allergies?
- Is there anything else you think I should know about your health?
- *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.
- Describe your sleep (how many hours, the quality of your sleep, do you feel rested)
- Do you drink any of these? If yes, how much?
- Water
- Coffee
- Pop
- Tea
- Alcohol
- Other
- When do you eat your first meal of the day?
- How often do you eat out/get takeout?
- Describe your daily eating pattern (ex; breakfast, lunch at work, a snack, and dinner)
- How many hours a day do you sit?
- Do you exercise at all?
- What types of physical activity do you enjoy?
- On a scale from 1-10, how fulfilled are you?
- What do you do for work?
- What area in your life tends to be the biggest stress for you?
- On a scale 1-10, how healthy would you rate your surroundings?
- Is there anyone in your life who would like to get healthy with you?
- Should be Empty: