Betsy Glass Health Coach
Health Assessment
Name
Date
/
Month
/
Day
Year
Date
Address
Address
ST
Zip
Phone
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
/
Month
/
Day
Year
Date
Please describe WHY you are interested in getting healthy. (What is your main Motivation Relationships, activities, how you will feel, etc?)
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if thats part of your goal)?
Describe where you are in your health now. Weight, sleep, stress, energy, etc
Describe where you would like to be in your health.
How would you rate your energy level?
How did you hear about our program?
Preferred Form of Contact
Call
E-mail
Text
How much water do you drink each day?
Coffee +How Do you drink it? Cream? Sugar? Black?
Soda
Tea
Alcohol
What physical activities do you participate in?
How many times a week do you exercise?
How would you rate your stress level?
What do you do for work?
How much do you enjoy what you do?
Are you Pregnant?
Yes
N
Are you Nursing and How old is your baby?
Are you taking any medications for
Diabetes Type 1
Diabetes
Diabetes Type 2
High Blood Pressure
High Cholesteral
Anxiety/Depression
Thyroid
When do you eat your first meal?
How many meals per day do you eat?
When do you eat last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Favorite Restaurants?
Are there any food or other allergies that I should be aware of?
Current Weight
Goal Weight
Height
Are you taking other medications or do you have other medical conditions that could influence which program we chose?
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
DAILY ROUTINE & HABITS
How many hours of sleep do you typically get?
What time do you typically go to bed?
Quality of Sleep?
Do you wake up feeling rested?
How healthy would you rate your surroundings? Do you have healthy & active friends, supportive family, keep junk food in the house, etc.?
Is there anyone in your life who would like to get healthy with you?
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