Client Health Assessment
Aimee Coffey -Optavia Health Coach
Welcome to Your Wellness Assessment
First Steps
Celebrate Health for you
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to contact you
Home number
Mobile number
Email
Text
Age
How did you hear about me or our programs?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
Medical
Are there any food allergies or other allergies that I should be aware of?
Do you have any of these conditions
Type 1 Diabetes
Type 2 Diabetes
PSCOS
Kidney Disease
Gout
other
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Very Good
Good
Poor
Fair
Excellent
How much water do you drink each day
Do you consume any other beverages
Coffee
Tea
Soda
Beer, Wine, Alcohol
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
1-3
4-5
6-8
7-10
Do you currently exercise? If so, how many times a week?
How would you describe your daily activity level?
What physical / exercise activities do you participate in?
Are you taking any Supplements? If so, which ones?
Are you or have you ever taken essential amino acids?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for a living?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Please share any additional comments or questions.
Submit
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