HEALTH ASSESSMENT

HEALTH ASSESSMENT

Jennifer Lewis-HEALTH COACH
Name
Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ST
Zip
Phone
Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
How did you hear about our program?
Proferred Method Of Contact
Proferred Method Of Contact
Describe where you are in your health now. Weight seep stoss. eneryy etc)
How much water do you drink each day?
HYDRATION How much water do you drink each day?
Coffee
Soda
Tea
Alcohol
Describe where you would like to be in your health.
How would you rate your energy level?
What physical activities do you participate in?
How many times a week do you exercise?
Please describe WHY you are interested in getting heallhy. (Mhat is your main Motivation.. Relationships, activitios, how you will foot etc)
Are there things you can't do that you would like to be able to?
Are there things you can't do that you would like to be
How would you rate your stress level?
When was the last time you remember feeling your best in your health or being at your ideal weight or thats part of your goal?
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
Are you Nursing?
# yes. how old is your boby?
How many meals per day do you eat?
Are you taking any medications for
When do you eat your first meal?
When do you eat last meal?
Do you snack between meals?
Thyroid
What kind of snacks?
Are theve any food or other allergies that - should be aware of
Are theve any food or other allergies that - should be aware of
Cournadin (Warfarin)
How many times a week do you eat out?
Are theve any food or other allergies that should be aware of
Where?
Current Weight
Goal Weight
Height
Are you toking other medications or do you have other medical conditions mat could infuence which program we choose:
Have you fried to lose weight before?
Research shows that there are 7 signaficant foctors that contribute to overal physical health.
What has been most difficult about losing/maintaining weight in the past?
SURROUNDINGS (On a scale of 1-10)
How healthy would you rate your surroundings?
Do you hove heathy & octive friends supportive family, keep junk food in the house etc
What time do you typically go to bed?
(Do you hove heathy & octive friends supportive family, keep junk food in the house etc.)
Wake up?
Quality of Sleep?
Do you wake up feeling rested?
Is there anyone in your life who would like to get healthy with you?
Should be Empty: