HEALTH ASSESSMENT
Name
Email
example@example.com
Phone
Format: (000) 000-0000.
Time Zone
Current Weight
Desired Weight
How tall are you?
How young are you?
I would love to hear what you would like to accomplish with your health. Weight-loss, improved sleep, better response to stress, etc
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
What have you done to try to lose weight in the past?
What have been your biggest barriers to reaching and maintaining your health and weight goals?
MEDICAL HISTORY (Check all that apply.)
High Blood Pressure
Diabetes Type I
Diabetes Type II
Gout
Thyroid
Gluten Intolerance or
Coumadin (Warfarin)
Other medications:
Soy Allergy or
Food Allergies
Other
Heart attack
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
On a scale of 1-10, what is your energy level throughout the day?
MOTION
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
MIND
On a scale of 1-10, how fulfilled are you?
On a scale of 1-10, how much do you worry?
What area(s) of your life tends to be the biggest stressor for you?
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?
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 much and how often?
SURROUNDINGS
On a scale from 1-10, how healthy would you rate your surroundings (family, coworkers, keep junk food in the house, etc.)
Is there anyone in your life who would like to get healthy with you?
Submit
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