HEALTH SURVEY
Cat Cousino - Simple Mindful Changes
Date
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Month
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Day
Year
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Name
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First Name
Last Name
Email
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example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
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Month
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Day
Year
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Phone Number
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Format: (000) 000-0000.
If you were referred, by who?
Name
Or how did you come by this health survey?
Source
Preferred Method of Contact
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Call
Email
Text
MEDICAL
Do you have any of the following medical conditions?
High Blood Pressure
Diabetes Type 1
Diabetes Type 2
Gout
Are you taking any medications for:
Diabetes
Thyroid
High Blood pressure
Lithium
High Cholesterol
Coumadin (Warfarin)
Are you pregnant?
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Yes
No
If yes, are you nursing?
Yes
No
If yes, how old is your baby?
Do you have any food allergies? If yes, please describe.
Are you a vegetarian and/or do you have diet restrictions (ie. gluten or spicy foods).
SLEEP
What time do you usually go to bed at?
What time do you usually wake up at?
How many hours do you usually sleep per night?
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How is your quality of sleep?
Do you wake up feeling rested?
Hydration
How much water do you drink in a day?
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How much coffee do you consume in a day?
If you drink coffee, what do you put in it?
How much alcohol do you drink per week?
Movement
How many times a week do you exercise?
What kind of exercise do you participate in?
Are there things you would like to do that you currently are not physically able to do?
How would you rate your daily energy level?
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2
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5
Stress
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
How would your rate your stress level?
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5
Eating habits
When do you eat your first meal?
When do you eat your last meal?
How many meals do you eat per day?
Do you snack? If yes, on what?
How often do you eat out in a week?
Where do you eat out at?
Weight
Current weight
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Goal weight
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What is your height?
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Have you tried to lose weight before?
If yes, what have you found most difficult about losing weight in the past?
Are you interested in seeking medical assistance, utilizing tools such as Wegovy, semiglutides and other GLP-1 medications?
✨ Are you interested in exploring the opportunity to become a coach?
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Yes, I’d like to view info on this.
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