Form
Health Assessment
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Time Zone
Current Weight
Desired Weight
How tall are you?
How young are you?
I would love to hear what you would like to accomplish with your health. Weight-loss, improved sleep, better stress response, etc.
What is your main motivation for wanting to make changes to your health? Relationships, activities, personal self-image, health conditions, etc?
What have you tried in the past to lose weight and improve your health?
What have been your biggest barriers to reaching your health and weight goals?
MEDICAL HISTORY (Check all that apply)
High Blood Pressure
Diabetes Type I
Diabetes Type II
Gout
Gluten Intolerance/Celiacs Disease
Thyroid
Coumadin (Warfarin)
Soy Allergy
Other food allergies
Heart Attack
Other medical condition not listed
Medications
How many hours of sleep do you get in a typical. night?
On a scale of 1-10, what is your energy level throughout the day?
How many hours a day do you sit?
How many days a week do you exercise? (0-7)
What kind of exercise do you participate in regularly?
What area(s) of your life tend to be your biggest stressors for you?
What is your occupation?
On a scale of 1-10, how much do you enjoy what you do for a living?
How many meals and snacks do you eat per day?
What time do you eat your first mean of the day?
How many times a week do you eat out? Where do you tend to eat out?
How many ounces of water do you drink each day?
What other beverages do you drink each day/week? (coffee, soda, alcohol, tea, etc) How many, how often?
Who in your life and surroundings would be a good partner to get healthy with you?
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