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, 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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Your Health Goals & Current Habits

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS