HEALTH ASSESSMENT
Angel Collazo-Certified Health Coach
Today's Date
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 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Name
*
Phone
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Format: (000) 000-0000.
Email
*
example@example.com
Social Media Profile Name
Who referred you?
If you were referred, please put the name of the person who referred you OR where you saw this link.
Let's Discover Where You Are & Where You Want to Be!
If success were guaranteed, what would you like to accomplish with your health?
Weight Loss
Improved Sleep
Weight Gain
Gain Energy
Build Muscle
Better Response to Stress
Other
Are you taking any of the following medications or have any of the following allergies? If medication/allergy/medical condition is not listed, please list in the other option.
High Blood Pressure
Diabetes
Diabetes Type I
High Blood Pressure
Diabetes Type II
Gout
Thyroid
Gluten Intolerance or Allergy
Lithium
Coumadin (Warfarin)
Soy Allergy
Food Allergies
Other
Are you Pregnant?
Yes
No
Are you Nursing?
Yes
No
If yes, how old is your baby?
Do you have any allergies or medical conditions not mentioned above that could influence the system we design for you?
Do you have any food aversions-tastes, texture, etc- that you cannot take? Please list below.
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
What is typically the biggest obstacle when it comes to reaching your goals? For example: Not enough time, I don't know what to eat, I don't have accountability or community, easily discouraged when I see slow progress, not aware of the habits that are hindering my progress.
Can you 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?
MOTION
Do you currently take any supplements to support exercise?
Essential Amino Acid
Protein
Creatine
Preworkout
Other
Are there things you can't do now that you would like to do?
How many days a week do you exercise? (0-7 days)
What types of physical activity do you enjoy in general? Think movement over exercise.
MIND
On a scale of 1-10, how fulfilled are you currently with where you are in your health & life?
On a scale of 1-10, how much do you currently worry about your health, family, life in general?
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?
What do you believe is keeping you from losing weight? Gaining weight? Increasing energy? Reaching whatever the goal is that you set for yourself?
FOOD & HYDRATION
How many meals and snacks do you eat per day?
What time do you eat your first meal of the day?
Do you prefer sweet foods, savory foods, or a blend of the two?
How many times a week do you eat out? And where? Include beverages, snacks, etc.
The average American spends approx. $15-$20 a day/per person on groceries, beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average?
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$10
$15
$20
$25+
Do you enjoy drinking water?
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Love it!
Not a fan!
It's okay with some flavor.
Like it, but need to drink more.
Other
How many ounces of water daily?
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.)
Is there anyone in your life that you would like to get healthy with you?
Is there anything else you think I should know about your health?
After seeing what's possible, rate on a scale of 1-10 how ready are you to make the changes necessary to make your goals become your reality.
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