Hope4Health4Life Health Survey

Form

Hope4Health4Life Health Survey
Name

First NameLast Name
Email
example@example.com
Best number to reach you at
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
How did you hear about me or my program?

Other
If other, please answer here.
Please describe WHY you are interesting in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
How many hours of sleep do you typically get?
How is your quality of sleep and do you wake up feeling rested?
How much water do you drink each day?
Do you consume any other beverages? Coffee, Soda, Tea, Alcohol
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times per week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any stressors in your life?
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs,fast food, sit down restaurants, taking out, vending machines, etc)
Current weight: (If you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
How healthy would you rate your surroundings? (on a scale of 1-10)
Are you currently taking any medications or have allergies? If so please list.
Are you using a form of medical weight loss (shots)?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

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