Health Survey
Full Name
*
First Name
Last Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Today’s Date
-
Month
-
Day
Year
Date
Age
How did you hear about me or our programs?
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
Medical
Are you pregnant?
Please Select
Yes
No
Are you nursing?
Please Select
Yes
No
If yes, how old is your baby?
Do you have the following?
Diabetes - Type 1
Diabetes - Type 2
High Blood Pressure
Gout
Kidney Disease
PCOS
Is there any food allergies or other allergies that I should be aware of?
Are you taking any medications for:
Diabetes
High Blood Pressure
High Cholesterol
Thyroid
Blood Thinners
Other
Please list any medications or supplements you are currently taking:
Sleep
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
Please Select
Sedentary
On your feet
Active
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight:
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: