Health Assessment Inquiry:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
How did you hear about us?
Please Select
Facebook
Instagram
Friend
Family
Other (please specify)
Please fill out the following document to give me a clear picture on where you are with your health & habits, and where you would like to go with them.
If failure wasn't an option, what is a dream health goal you have for yourself?
When you reach that goal, what things will you start doing that you might not be doing now (what would be more enjoyable to do, such as swimming, taking photos, being active)?
Now that you're at this point, how do you imagine what your overall emotional health will look like?
Tell me about a time in your life when you felt good? What has changed between then and now?
How many hours of sleep do you get, do you feel rested?
Scale of 1-10, what are your energy levels? (10 being highest)
Do you have an exercise routine?
On a scale of 1-10, what are your stress levels? (10 being highest)
How many oz. of water do you drink? Do you drink anything else?
How many times a day do you eat?
Do you snack?
Do you take any medications and/or have any health concerns?
Did someone refer you:
yes
no
Tell us who referred you:
Rows
Full Name
Contact Number
1
When is the best time for me to contact you to give you more information about your health plan and see if it is a right fit for you?
Starting weight
Desired weight
Submit
Should be Empty: