HEALTH EVALUATION

Health Evaluation

Congratulations on taking your first step toward optimal health! I am excited to learn more about you and your goals so that I can know specifically how our program could help you create the health and life you deserve! I'll be in touch with you within 24 hours of you filling this out. I look forward to talking! My best, Shauna Davis
Name*
Phone*
Format: (000) 000-0000.
Email*
Preferred Method of Contact*
Address*

Street Address

CityState / Province

Postal / Zip Code
Referred From? *
STEP ONE: GOALS & MEDICAL INFORMATION
1. What would you like to accomplish with your health? This could be weight-loss, improved sleep, better response to stress, etc. *
2. What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc*
3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?*
4. Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?*
NoYes
NoYes
DiabetesHigh Blood PressureLithium*ThyroidCoumadin (Warfarin)Other
High Blood PressureDiabetes - Type 1Diabetes - Type 2GoutGluten Allergy or IntoleranceSoy Allergy or IntoleranceFood Allergy (Medically Diagnosed)Other
*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.
STEP 2: DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?*
How would you describe the quality of your sleep?*
On a scale of 1-10, what is your energy level throughout the day?*
MOTION
How would you describe the quantity & quality of the activity you do each week?*
How many hours a day do you sit?*
How many days a week do you exercise? (0 - 7 days)*
What types of physical activity do you enjoy?*
MIND
On a scale of 1-10, how fulfilled are you?*
On a scale of 1-10, how much do you worry?*
What area of your life tends to be the biggest stress 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 often and how much?*
WEIGHT MANAGEMENT
Age*
Height*
How much do you currently weigh?*
What would you consider to be a healthy weight for you?*
Have you tried to lose weight in the past?*
What has been difficult for you about losing and maintaining weight?*
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, keep junk food in the house, etc*
Is there anyone in your life who would like to get healthy with you?*
Is there anything else you think I should know about your health?*
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Health Evaluation

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS