Health Assessment for Nutrition Coaching

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Welcome

Welcome

Hi there, please fill out and submit this quick health assessment form. Be as detailed as you feel comfortable with so we can create the best plan for you. We will contact you soon to schedule your FREE consultation!

36Questions

1
Full Name
First Name
Last Name
2
Email
example@example.com
3
Phone Number
Please enter a valid phone number.
4
Preferred Method of Contact
Phone Call
Text
Email
5
Best Time To Contact
Morning (9am-12pm)
Afternoon (12pm -4pm)
Evening (4pm-8pm)
6
Describe your health & fitness goals (weight loss, tone, better sleep, improve health / reduce symptoms, etc)
Huge
Large
Normal
Small
Ok
Ok
7
What is your motivation or reason for wanting to achieve your goals? (What's your "why")?
Huge
Large
Normal
Small
Ok
Ok
8
Tell me about a time when you were healthier. What has worked in the past, what hasn't?
Huge
Large
Normal
Small
Ok
Ok
9
Do you have any health conditions?
Diabetes (Type I)
Diabetes (Type II)
Gout
Hypothyroidism
Hyperthyroidism
High Blood Pressure
Coumadin (Warfarin)
Inflammatory Condition (RA, PCOS etc)
10
Are you currently
Pregnant
Planning to become pregnant
Nursing
11
List any medications you currently take
12
List any vitamins, supplements or protein you currently take
13
Do you have any special dietary needs, allergies or intolerances?
Gluten Free
Dairy Free
Soy Free
14
Have you had bariatric (weight loss) surgery?
YESNO
15
How many hours of sleep do you get in a typical night?
16
How would you describe the quality of your sleep?
Excellent
Poor
Could be better
17
On a scale of 1-10, what is your energy level throughout the day?
18
What activities do you engage in on a typical day?
19
How many hours per day do you sit?
20
Do you exercise? (type, frequency & duration)
21
On a scale of 1-10 how fulfilled are you?
22
On a scale of 1-10 what is your level of stress or worry?
23
What area of your life tends to cause the most stress / worry?
24
What is your occupation?
25
On a scale of 1-10 how much do you enjoy what you do for a living?
26
How many times do you eat throughout the day? (meals & snacks)
27
What time do you typically have your first meal of the day?
28
How many ounces of water do you typically drink per day?
29
Are you comfortable sharing your age?
30
How tall are you?
31
What is your current weight?
32
What would you consider a healthy weight for you?
33
Have you tried to lose weight in the past? Were you successful?
34
Is there anyone in your life who would like to get healthy with you?
35
Is there anything else you think I should know about your health or goals?
36
Who Referred You?
Should be Empty:

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