Health Assessment Consult
Please complete this form to schedule a FREE health assessment
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How old are you?
How tall are you?
What would you consider to be a healthy weight for you?
Let's talk about your goals
What would you like to accomplish with your health?
Weight loss
Improve Health
Feel better
Improved Energy
Fit better in clothing
Be more active
Better muscle definition
Better sleep
Handle stress better
What is your primary motivation for wanting to make changes to your health?
What activities are you looking forward to participating in as you reach your goal
What are programs or diets have you tried and when?
What has been difficult for you about losing and maintaining weight
Health Considerations
Are you taking medications for?
Diabetes Type 1
Diabetes Type 2
High Blood pressure
Thyroid
Coumadin (Warfarin)
Lithium
NONE
Other
Do you have any of the following conditions
High blood pressure
Diabetes Type 1
Diabetes Type 2
Gout
None
Other
Do you have allergies or sensitivities
Gluten
Soy
Eggs
Dairy
None
Other
Are you Nursing?
Pregnant
Breastfeeding
NO
DAILY ROUTINE & HABITS
Please complete these questions in order for me to provide a proper dietary analysis. Base on the information provided I will be able to match a personalized plan for you.
How many meals and snacks do you eat per day total?
How often do you drink or do this? (please select one in each row)
NEVER
1-5X/WEEK
5 +/WEEK
Coffee
Restaurant
Take-out food
Snacks
What type of beverages do you typically drink? (please select one in each row).
NEVER
SOEMTIMES
OFTEN
TOO MUCH
NOT ENOUGH
Water
Pop/Soda
Coffee
Tea
Alcohol
Other
Please rate yourself in the following categories (please select one in each row).
POOR
GOOD
OPTIMAL
Weight status
Eating Habits
Physical Activities
Sleep
Relaxation
Stress
Finances
How many hours of sleep do you get each night?
On a scale of 1-10 how would you describe your sleep. Do you wake up rested and refreshed?
1 being the lowest and 10 being the highest
On a scale of 1-10 what is your energy level throughout the day?
1 being the lowest and 10 being the highest
How many days a week do you exercise
How many hours a day do you sit
How would you rate your stress level on a scale of 1-10
1 being the lowest and 10 being the highest
What area of your life tends to be the biggest stress for you?
Please rate yourself in the following categories: (please select one in each row)
POOR
GOOD
OPTIMAL
Relationships
Work satisfaction
Spiritual time
Hobbies and Fun
Financial Abundance
Money Management
Community contribution/service
On a scale of 1-10, how healthy would you rate your surroundings?
1 being the lowest and 10 being the highest
Did you know that the average American spends $15-25/day on anything they consume (eat/drink)? What would you say that you spend per day?
Is there anyone you would like to get healthy with?
Is there anything else I should know about your health?
Where are you now (please select one from each row)
POOR
GOOD
OPTIMAL
Physical Health
Mental Health
Financial Health
When is a good date to go over your responses
-
Month
-
Day
Year
Date
Best time to call?
Hour Minutes
AM
PM
AM/PM Option
What is your time zone
Please Select
EST
CST
MST
PST
Submit
Should be Empty: