Initial Health Consultation

INITIAL HEALTH CONSULTATION
Name*

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

Street Address

Street Address Line 2

CityState

Zip CodeCountry
How did you hear about our program?*
If you were referred, name of the person who referred you.
Are you on social media? If so, what platforms and under what name, if different from above?
AWAKEN

Discover where you are and where you want to be!
Describe where you are in your health now and where would you like to be. (Weight, sleep, stress, energy, etc)*
Describe WHY you are interested in getting healthy. (What is your main motivation...relationships, activities, how you feel, etc.)*
When was the last time you felt your best (weight or size, if that's part of your goal) and what would it be like to be there again?*
MEDICAL
YesNo
YesNo
If yes, how old is your baby?
Diabetes - Type 1Diabetes - Type 2High Blood PressureGoutNo Medical Considerations
Are there any food sensitivities or allergies that I should be aware of?*
DiabetesHigh Blood PressureHigh CholesterolLithium*Thyroid**Coumadin (Warfarin)***None of the above
Are you taking other medications or have other medical conditions that could influence which program we choose?*
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
SLEEP
How many hours of sleep do you typically get?
What time do you typically go to bed and wake up?
How is your quality of sleep? Do you feel rested?
HYDRATION
How much water do you drink each day?
CoffeeSodaTeaAlcoholMilkEnergy DrinksJuiceOther
MOTION
How would you rate your energy level? (scale of 1-10; 1 is low and 10 is “a toddler on the run”)
Do you feel you have an active or sedentary lifestyle?
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? (scale of 1-10; 1 is low and 10 is off the charts)
Is a majority of your stress from work, your personal life, or both?
What do you do for work?
How much do you enjoy what you do?
EATING HABITS
How many meals per day do you eat?
When do you eat your first & last meal?
If you snack between meals, what kind?
How many times a week do you eat out?
Where & what types of meals do you eat out?
The typical American spends between $15-$20 a day on food. Does that sound about right for you? If not, what do you think you spend?
WEIGHT
What is your current weight and height?
Date of Birth

MonthDayYear
Date
What has been most difficult about losing/maintaining weight in the past?*
If you could not fail, how much weight would you like to lose?
SURROUNDINGS
How healthy would you rate your surroundings? (scale of 1-10; 1 is unhealthy and unsupportive & 10 is very healthy and supportive)
As you are thinking of getting healthy, are there friends or family members you would want to do this with, or you would like to help get healthy?
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INITIAL HEALTH CONSULTATION

AWAKEN

MEDICAL

SLEEP

HYDRATION

MOTION

STRESS

EATING HABITS

WEIGHT

SURROUNDINGS

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