HEALTH ASSESSMENT

Health Profile - Your Journey to a Healthier Lifestyle!

I am so happy you are taking the first step towards creating a healthier lifestyle! I am a national board certified health & wellness coach (NBC-HWC) and am very passionate about wellness coaching. I think it is that missing link that seems to make the difference for people to go the distance to making sustainable changes. I look forward to setting up your complimentary weight loss/health consultation call! Please fill out as much of the following information under each section as possible and submit. This will help me to best assist you. I will reach out to you soon! If you have any questions in the meantime, feel free to call or text me at (312) 208-8838 or email me at sarah@sarahacoaching.com.
Date*

MonthDayYear
Date
Name

First NameLast Name
Take Photo
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone*
CellHomeWork
Email*
example@example.com
Preferred Method of Initial Contact

Phone CallText MessageE-mail
Date of Birth

MonthDayYear
Date
What would you like to accomplish with your health? (Weight loss, improved sleep, more energy, better nutrition, better response to stress, etc.)*

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What is your main motivation for wanting to make changes to your health?(Relationships; activities; how you will feel and look; and/or desire to reduce or avoid taking medications for chronic lifestyle diseases like pre-diabetes, Type 2 Diabetes, high cholesterol, or high blood pressure, etc.)*

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Can you tell me about a time in your life when you were healthier? What has changed between then and now?*

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Medical
Tell me about your health: Do you have any medical conditions that could influence which Program we choose?**

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Are you Pregnant

YesNo
Are you Nursing

YesNo
If yes, how old is your baby?
Are you taking any medications for:

DiabetesHigh Blood PressureLithium (1)Thyroid (2)Coumadin/Warfarin (3)High CholesterolOther Medications
What other medications (including frequency and dosages) are you taking?
¹Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor.

²Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.

³Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
Do you have the following:

Type 1 DiabetesType 2 DiabetesPre-diabetesHigh Blood PressureHigh CholesterolFood or Other AllergiesGout
Do you have any food or other allergies or sensitivites?
DAILY ROUTINE & HABITS
How many hours of sleep do you typically get?
What time do you typically go to bed?
Quality of Sleep?
What time do you typically wake up?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much of other beverages?
Coffee
How do you take it? (black, milk, sugar, half & half, Coffeemate,...)
Soda
Regular, diet
Tea
Alcohol
Juice or Other Beverages
Energy drinks, juice, Kombucha, ...
MOTION
How would you rate your energy level?
(On a scale of 1-10 with 1 being low energy and 10 being high energy)
Do you find your energy level is consistent during the day or you have peaks and valleys? If not consistent, please elaborate.
What physical activities (non-exercise) do you enjoy participating in?
How many times a week do you exercise?
Are there things you can’t do that you would like to be able to do or do as well as you would like to because of your current health status?
STRESS
How would you rate your stress level?
(On a scale of 1 to 10 with 1 being low stress and 10 being high stress)
What do you do for work?
Which area(s) of your life tend to be the biggest source(s) of stress?
How much do you enjoy what you do?
EATING HABITS
How many meals per day do you eat?
When do you eat your first meal?
When do you eat last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Do you follow a particular eating plan or type of eating?
Vegetarian, vegan, keto, intermittent fasting, etc.
Which restaurants do you tend to frequent?
WEIGHT
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
If you have previously tried to lose weight, please describe the method(s) you used for weight loss?*

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What has been most difficult about losing/maintaining weight in the past? *

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SURROUNDINGS
How healthy would you rate your surroundings? (On a scale of 1-10 with 1 being poor surroundings and 10 being great surroundings)
Do you have healthy & active friends, supportive family, keep junk food in the house, etc
Is there anyone in your life who would like to get healthy with you?
Should be Empty:

Health Profile - Your Journey to a Healthier Lifestyle!

Medical

DAILY ROUTINE & HABITS

HYDRATION

MOTION

STRESS

EATING HABITS

WEIGHT

SURROUNDINGS