Health Questions

Health Assessment Questions

This brief, confidential questionnaire is designed to assess whether our programs can help you reach your health goals.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address (U.S.)*

Street Address

Street Address Line 2

CityState

Zip Code
Are you a senior (age 65+) or a teen?*

I am a senior (age 65+)I am a teenNeither of these
If comfortable sharing, what is your current age?
ex. 45
Coaching Preferences

Let's talk about utilizing your coach
Who is your Health Coach contact? (the person who sent you this link)*
On a scale from 1 to 10 (10 being highest), how important do you feel utilizing your coach will be in helping you succeed on your health journey?*
1=No coaching needed / 10=All in
What's your primary communication preference FOR TALKING WITH YOUR COACH? (check-ins, questions, etc.)*

TextInstagram MessengerFacebook MessengerWhatsAppEmailPhoneOther
What's your primary communication preference FOR RECIEVING INFORMATION from your coach? (instructions, links, printing, etc.)*

TextInstagram MessengerFacebook MessengerWhatsAppEmailPhoneOther
Health

Let's talk about your current health
Do you have any of the following conditions (check all that apply)*

Diabetes type I or II, or prediabeticGoutHigh Blood PressureFood allergies/sensitivitiesGallbladder issuesPCOSThyroid conditionIBS or similarLiver diseaseNone of the aboveOther
If you marked any existing conditions (or "Other"), please give additional details
ex. allergic to soy
Do you take any of these medications (check all that apply)*

LithiumCoumadin® (Warfarin)Insulin or Diabetes MedicationBlood Pressure MedicationThyroid MedicationGLP-1 compound medications (such as Wegovy, Zepbound, Ozempic, Mounjaro, or others)ContraveMetforminOrlistatNone of these
Do you have any dietary restrictions or preferences*

Vegetarian or veganGluten-freeSoy intoleranceDairy intoleranceNone of theseOther
Are you pregnant or a nursing mother?*

Yes, pregnantYes, a nursing motherN/A
If you're a nursing mother, tell me about your baby and how breastfeeding is going?
Skip if it doesn't apply to you
Movement

Let's talk about your current level of exercise and activity
How would you describe your activity level in the LAST 30 DAYS?*

sedentaryexercise occasionallyexercise regularlydon’t exercise but very activeOther
If you exercise or are active, give more details on that here
ex. walk dog 15 minutes a day
What’s your occupation and how active is it? (If you’re a SAHM, list how many children and ages).*
ex. clerk, desk job
Hydration

Let's talk about your current level of hydration
About how much water do you drink daily?*
ex. 24 ounces
Do you drink other beverages (coffee, tea, soda, alcohol, etc.), If yes, how often and how much?*
ex. coffee, 2 cups a day
Nutrition

Let's talk about your current eating
Tell us a bit about how you eat now... What does a typical day as far as meals go look like? What are your go-to meals?*
Do you eat / like vegetables?*

YesSomeMostNot many or none
How often do you eat out?*

RarelySometimesOftenA lot
Rest & Stress

Let's talk about your current levels of physical stress
On average, how many hours a night do you sleep?*
ex. 8 hours
If you sleep less than 8 hours, tell us what keeps you awake at night
ex. pain, stress, baby
What are the biggest areas of stress in your life RIGHT NOW?*
ex. work, marriage, finances
What are ways you currently deal with stress (good and bad)?*
ex. alcohol, yoga
Habits

Let's talk about your current or past habits
What eating habits do you struggle with? (check all that apply)*

Emotional eatingBored eatingSnacking and/or mindless eatingMake unhealthy food choicesCrave sweetsEating out too muchOvereating and/or portion sizesLate night eatingNot eating and then getting too hungryNone of theseOther
If you've tried to lose weight in the past, what have you tried?*
If you haven't tried in the past just put "N/A"
OTHER THAN THE HABITS YOU LISTED ABOVE, if you tried to lose weight in the past, what were your biggest struggles with staying on program, succeeding, or keeping the weight off long-term?*
If you haven't tried in the past just put "N/A"
If you've tried to lose weight in the past, what were your strengths when trying to lose weight or keep it off?
If you haven't tried in the past just put "N/A"
Goals

Let's talk about your health goals
If comfortable sharing, what's your current weight AND height?
pounds & feet/inches
If you set a dream worthy goal, how many pounds would you like to lose?*
pounds
What do you envision that losing weight or getting healthier will help you achieve?*
ex. feel better, less inflammation, do more activities with kids, more confidence, etc.
One a scale of 1 to 10, how much do you want to lose the weight you listed above and achieve your health goals?*
1 - 10 (10 being the highest)
How important do you think accountability is to success? Does "dieting in the dark" work?*
Is there anything else about your general health or your goals that we should know?
By signing, I declare I have provided all relevant health information.*

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Health Assessment Questions

Coaching Preferences

Health

Movement

Hydration

Nutrition

Rest & Stress

Habits

Goals