Health Assessment 2022
Suzanne Latapie IIN Certified Health Coach, Exhale Fitness Certified Teacher, Optavia Health Coach
"The Journey of a Thousand Steps begins with one step"-Lao Tzu I am totally committed to helping you live your best life!
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Name
First Name
Last Name
Date
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Month
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Day
Year
Date
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
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Day
Year
Date
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Describe where you are in your health now. Weight, sleep, exercise, energy
What is your top challenge?
Why are you interested in improving your health at this very moment?
What is your number 1 goal in improving your health, the one thing that would improve all the other challenges?
How much do you move daily if possible, a step count
Do you have any serious illnesses/hospitalization/injuries?
When did you feel that your were at the top of your game, in terms of health and well-being?
How is/was the health of your mother and father
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Medical
If you are a female, are you pregnant? Nursing?
If you have children, how old are/is your child/children
Do you have diabetes, high blood pressure, high cholesterol, thyroid condititons?
Do you take these medications: statins, lithium, coumadim?
Do you take any other medications?
What supplements do you take?
Sleep
How many hours of sleep do you get, do you have sleep apnea
Do you wake up at night frequently? Do you urinate often during the night? Can you return to sleep easily?
What time do you go to bed and wake up? Do you allow some time between eating and sleeping?
Do you take anything to help you sleep? Include tea/supplements.
Do you wake up feeling refreshed?
Hydration
How many ounces of water do you drink daily? Do you drink diet/regular sodas?
How much coffee and about what time is the last coffee?
How many glasses of alcohol and/or glasses of wine per day/week. What time is the last glass?
Movement
On a scale of 1-10, how is your daily energy?
How many times a week do you exercise?
What physical activities do you participate in? Is it daily, weekly?
Are there things you can't do and would like to do?
How fast can you get up from a chair? How is your balance?
Stress
On a scale of 1-10, rate your stress level?
Do you work and what do you do?
Do you enjoy your job?
Are there other things in your life that stress you?
Do you have a group of friends you regularly speak to, family, or faith-based group?
Eating Habits
Do you eat something green every day?
What kind of snacks do you have?
How many times a day do you eat?
When do you eat your first meal and your last meal?
Do you eat junk food? Sugary beverages?
How many times a week do you cook at home?
Weight history
Current weight
Goal weight
Height
Have you tried to lose weight before?
What has been the most difficult challenge in losing/maintaining weight loss in the past?
Surroundings/Community
How healthy would you rate your home/work/friends on a scale of 1-10?
Have you ever gone through your cabinets and eliminated foods that may be unhealthy?
Do you have anyone in your life that would like to get healthy with you?
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Relationship Status
Children names and ages
Occupation and hours per week
Pets
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