Your Health Goals & Current Habits

Your Health Goals & Current Habits
Name*
Email*
example@example.com
Preferred Method of Contact
Phone*
What would 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*
Think about a time in your life when you were healthier. What has changed between then and now?*
Do you have any allergies or medical conditions that could influence which Program we choose?*
Are you Pregnant or Nursing?*

Yes, PregnantYes, NursingNo
Are you taking any medications for and/or do you have the following?:*

High Blood PressureDiabetes Type IDiabetes Type IIGoutThyroidGluten Intolerance or SensitivityCoumadin (Warfarin)LithiumSoy Allergy or IntolerenceFood AllergiesOtherNONE OF THE ABOVE
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 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. so, how often and how much?*
WEIGHT MANAGEMENT
Age?*
Height?*
Current Weight?*
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 your about losing and maintaining your weight?*
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (Supportive and active family & friends, tempting 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?*
Date*

MonthDayYear
Date
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Your Health Goals & Current Habits

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS