Health Assessment
After you have completed this form you will be contacted to schedule a brief call. You are not obliglated to start by scheduling the call. We will go over your options. Thank you! - Felicia Owens Payment
Name
*
First Name
Last Name
Email
*
example@example.com
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.
Who referred you?
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What are you main goals in your health? What prompted you to want to know more?
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If you woke up tomorrow and you were at your ideal weight or health, what would be different from today?
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Tell me about a time that you felt healthy.
What do you do for work? Please mention how active your job is.
One to five, how stressful is your job?
No stress
1
2
3
4
Very stressful!
5
1 is No stress, 5 is Very stressful!
Do you follow a regular workout schedule? If so, how often and at what intensity? Please describe.
Tell me about your sleep
Night owl
Early bird
Restless sleep
Sleep like a rock
Other
Walk me through your typical day of eating. Please include what you’re drinking too.
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How often do you eat outside of the home? Drive thru, carry out, coffee stops, gas station snacks, vending machine...
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What is your current weight?
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What is your desired weight?
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How ready are you to make a change in your health?
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Not so much
1
2
3
4
5
6
7
8
9
Ready! NOW IS MY TIME!
10
1 is Not so much, 10 is Ready! NOW IS MY TIME!
I am looking forward to connecting with you soon about your health goals! In the mean time, I will add you to our private FB group with more information.
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