HEALTH ASSESSMENT Nagy on Fire

Name

First NameLast Name

Email

example@example.com

Date

Today's Date

Address

City

State

Two Letter Abbreviation

Zip Code

Phone Number

Format: (000) 000-0000.

Date of Birth

Date

How did you hear about our program?

If you were referred, name of person who referred you.

Awaken - Discover where you are and where you want to be!

Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)

0/330

Describe where you would like to be in your Health...

0/330

Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)

0/330

When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?

0/330

Medical

Are You Pregnant

Are You Nursing

If yes, how old is your baby

Do you have the following

Are there any food or other allergies that I should be aware of?

0/160

SLEEP

How many hours of sleep do you typically get?

What time do you typically go to bed?

What time do you typically wake up?

How is your quality of sleep?

Do you wake up feeling rested?

HYDRATION

How much water do you drink each day?

How much Coffee?

How much Soda?

How much Tea?

How much Alcohol?

0/50

MOTION

How would you rate your energy level? (on a scale of 1-10)

How many times a week do you exercise?

What physical activities do you participate in?

Are there things you can't do that you would like to be able to?

STRESS

How would you rate your stress level? (on a scale of 1-10)

What do you do for work?

How much do you enjoy what you do?

Are there other stressors in your life?

EATING HABITS

How many meals per day do you eat?

When do you eat your first meal?

When do you eat your last meal?

Do you snack between meals?

What kind of snacks?

How many times a week do you eat out?

Where?

About how much do you spend on food (groceries, eating out, drinks) in a day or month?

WEIGHT

Current Weight

Goal Weight

Height

On a scale of 1-10 (10 meaning ready to go!), how motivated are you to start working on your health goals?

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

0/200

SURROUNDINGS

How healthy would you rate your surroundings? (on a scale of 1-10)

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?

Thank you for your thoughful and honest answers regarding your current habits. Habit building is the key to long term success. I appreciate you taking the time to complete this form and would love to chat with you further to recommend which program would be the best fit for you. Let's schedule a time!