Stacy Morris Health Assessment

My Current Health Reality

I am thrilled that you are here. Please answer the following to help give me an idea of where you are currently in your health. Please know all information that you share with me will be kept confidential!
Name*

First NameLast Name
Preferred Email*
example@example.com
Date*

MonthDayYear
Today's Date
Phone Number*
Format: (000) 000-0000.
How did you hear about our program?
If you were referred, name of person who referred you.
TextCallEmail
Describe where you are in your health now... (weight, sleep, stress, energy, etc)*

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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
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 daily?*
What else do you drink daily (coffee, water, sodas)?
How much do you drink of those?
Do you drink alcohol? if so, how often?
If yes, how often and what type of alcohol?
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? Don't worry... It's okay if you don't exercise!
Are there things you can't do physically 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 and how many hours per week do you work?
How much do you enjoy what you do?
EATING HABITS
How many meals per day do you eat?*
Do you snack between meals?
What kind of snacks?
How many times per week do you eat out?*
What restaurants do you typically frequent?
How much do you spend daily eating out?*
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? What other programs have you tried? I did them ALL and failed multiple ones. So no worries, you are not alone! *

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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? If so who?
Is there anything else you would like to share with me?
Thank you for completing these questions. This truly helps to paint a picture of where you are currently in your health. Please text me at 205-901-0670 and let me know that you have submitted your answers so we can find a time to discuss which program is right for you. I am so proud of you for taking this first step toward improving your health! I am so excited to talk more with you soon! -Stacy Morris
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My Current Health Reality