HEALTH ASSESSMENT

HEALTH ASSESSMENT
Name
Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
STATE
Zip
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
How did you hear about our program?
Awaken...Discover where you are and where you want to be!
Describe where you are in your health now. Weight, sleep, stress, energy, etc)
Describe where you would like to be in your health.
Please describe WHY you are interested in getting healthy. (What is your main Motivation Relationships, activities, how you will feel, etc)
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if thats part of your goal)?
Medical

*We recommend that clients contact their healthcare provider before starting and throughout their weight loss journey.
Are Pregnant?
Are you Nursing?
If yes, how old is your baby?
Do you have the following:
Are you taking any medications for
Are you taking other medications or do you have other medical conditions that could influence which program we choose:
Are there any food or other allergies that I should be aware of
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
DAILY ROUTINE & HABITS
Research shows that there are 7

significant factors that contribute to overall physical health.
SLEEP
How many hours of sleep do you typically get?
Quality of Sleep?
What time do you typically go to bed?
Wake up?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
Coffee
Soda
Tea
Alcohol
MOTION (On a scale of 1-10)
How would you rate your energy level?
What physical activities do you participate in?
How many times a week do you exercise?
Are there things you can't do that you would like to be
STRESS (On a scale of 1-10)
How would you rate your stress level?
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
Eating Habits
How many meals per day do you eat?
When do you eat your first meal?
When do you eat last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Where?
WEIGHT
Current Weight
Height
Goal Weight
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
SURROUNDINGS (On a scale of 1-10)
How healthy would you rate your surroundings?
(Do you have healthy & active friends, supportive family, keep junk food in the house, etc.)
Is there anyone in your life who would like to get healthy with you?
Should be Empty:

HEALTH ASSESSMENT

DAILY ROUTINE & HABITS

SLEEP

HYDRATION

MOTION (On a scale of 1-10)

STRESS (On a scale of 1-10)

Eating Habits

WEIGHT