Your Health Goals & Current Habits
Name
*
Email
*
example@example.com
Preferred Method of Contact
Phone
*
Format: (000) 000-0000.
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, Pregnant
Yes, Nursing
No
Are you taking any medications for and/or do you have the following?:
*
High Blood Pressure
Diabetes Type I
Diabetes Type II
Gout
Thyroid
Gluten Intolerance or Sensitivity
Coumadin (Warfarin)
Lithium
Soy Allergy or Intolerence
Food Allergies
Other
NONE 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
*
/
Month
/
Day
Year
Date
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