Health Assessment

Let’s Get Started

Please answer these questions so we can build a plan to meet your needs.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Social Media Profile Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who referred you?
If you were referred, please put the name of the person who referred you OR where you saw this link.
WHERE YOU ARE & WHERE DO YOU WANT TO BE

This section will give me a better idea of your current health and your health goals.
Weight LossWeight GainBuild MuscleImproved SleepGain EnergyBetter Response to StressReduce InflammationOther
Diabetes Type IGluten Intolerance/AllergyDiabetes Type IISoy AllergyHigh Blood PressureFood AllergiesThyroidGoutCoumadin (Warfarin)LithiumNoneOther
YesNo
YesNo
Do you have any allergies or medical conditions not mentioned above that could influence the plan we customize for you?*
ChocolateVanillaStrawberryPeanut butterLemonCinnamonSoupsPastasChocolate chip cookiesBrowniePuddingBBQ chipsMashed PotatoesCaramelOatmealPancakesBlueberry BiscuitCoffee
What situations or factors are making your life difficult that you cannot prioritize your health.
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
Tell me about a time in your life when you were healthier? What has changed between then and now?
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?

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1 is HORRIBLE, 10 is EXCELLENT
Are there things you can't do that you would like to do?
How many days a week do you exercise? (0-7 days)
Describe your workouts. Include length of workouts and types of workouts, i.e. cardio, weightlifting, etc.
MIND
On a scale of 1-10, how fulfilled are you with where you are in your health & life currently?

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1 is NOT AT ALL, 10 is VERY FULFILLED
On a scale of 1-10, how much do you worry about your health, family, life in general currently?

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1 is NOT AT ALL, 10 is ALL THE TIME
What area of your life tends to be the biggest stress for you?
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?

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1 is I HATE IT, 10 is VERY HAPPY
What is the hardest part of being you right now?
FOOD & HYDRATION
How many meals and snacks do you eat per day?
When do you eat your first meal of the day?
How many times a week do you eat out? And where? Include beverages, snacks, etc.
$10$15$20$25+
Love it!Not a fan!It's okay with some flavor.Like it, but need to drink more.
How many ounces of water do you drink per day?
CoffeeSodaTeaWineAlcohol
How many cups of coffee? How do you take it?
How much soda/ice tea/energy drinks/other non-alcoholic beverages daily?
How much alcohol weekly or monthly do you consume? What are your drinks of choice?
WEIGHT MANAGEMENT
What is your current age?
How tall are you?
How much do you currently weigh?
How much do you want to weigh?
Have you tried to reach these health goals in the past? If so, what have you tried?
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (Consider things like - do you have healthy and active friends, supportive family, a lot of junk food in the house, etc.)

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1 is HORRIBLE, 10 is EXCELLENT
Is there anyone in your life who you would like to get healthy with you?
Is there anything else you think we should know about your health?
ARE YOU READY TO COMMIT TO YOURSELF?
What is one question you hope I don't ask you?
This program has 4 components: Coaching, Community, Education, and Nutrition. You will utilize all 4 components equally. Each one is just as important as the other for reaching your health goals and maintaining your results long-term.

You will understand how your body and brain can function optimally.
YESNO
I will love talking with someone regularly to help keep me on track with my goals!I will contact you occasionally if I have a question.I will enjoy interacting via text messages and that is enough for me.I am open.
I've been in a good fat burn before and I understand the concept.I've been eating poorly for a while and I'm not sure I can get back on track alone. Help!I keep trying, but I have a hard time finding the willpower to stay on plan long enough to see any results.I think I'm doing everything right, but I'm frustrated with my results and don't feel like I'm losing at the rate I should be alone. I’d like to troubleshoot with you.I've hit my goal and am struggling figuring out how to maintain my results. Help!
Additional comments you want me to know:
Should be Empty:

Let’s Get Started

WHERE YOU ARE & WHERE DO YOU WANT TO BE

SLEEP & ENERGY

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS

ARE YOU READY TO COMMIT TO YOURSELF?