Sarah Locke's Health Assessment Form

Knowing where you are now is essential in moving forward

"A healthy outside starts from the inside" ~Robert Urich
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Age
How did you hear about our programs?
Please describe your WHY to becoming a healthier version of yourself. (What is your main motivation? What would you be able to do that you are unable to do now? How different would your life be?)
When was the last time you remember feeling your best in your health or being at your ideal weight or size? (if that is part of your goal)
How committed are you to your health and wellness at this time?

Fully Committed, whatever it takesCommittedI'm going to give it a tryI just can't get motivated but have to do something
If you weren't able to answer above, "Fully Commited, whatever it takes" what is holding you back?
Healthcare Questions

This is to simply be sure we are aligning your health needs and restrictions into your individualized program development
Do you have any of the following?

Diabetes- Type 1Diabeters- Type 2High Blood PressureGoutKidney DiseasePCOS
Do you have any food allergies or dietary restrictions?
Please list any and all medications or supplements you are taking, and what you may be specifically taking them for
Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroidBlood ThinnersOther
Sleep
How many hours of sleep do you typically get per night?
What time do you typically wake up?
How is your quality of sleep? Do you rise feeling rested?
Hydration
How much water do you typically drink per day?
example: 8 oz is 1 cup, 64 oz is recommended
If you drink coffee, do you add anything to it?

I drink it blackCreamSugarCream and SugarOther
Do you consume any other beverages?

CoffeeSodaTeaAlcohol
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?
In a gym, at home, walking, any kind of movement
What physical activities do you participate in?
example of physical activity: Walking, hiking, swimming, biking, etc
How would you describe your daily activity level?
Low, moderate, high
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: (if you wish to share)
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 is empowered to get healthy with you?
Please list some dates and times in the next couple of days where you would be available for a 15 minutes phone call.
Should be Empty:

Knowing where you are now is essential in moving forward

Healthcare Questions

Sleep

Hydration

Motion

Stress

Eating Habits

Weight