HEALTH ASSESSMENT
Name
Date
/
Month
/
Day
Year
Date
Address
Phone
E-mail
Date of Birth
/
Month
/
Day
Year
Date
How did you hear about our program?
Describe where you would like to be in your health.
How would you rate your energy level 1-10?
What physical activities do you participate in?
How many times a week do you exercise?
Are there physical things you can't do that you would like to?
What is your weight loss goal?
Other goals?
How many meals per day do you eat?
When do you eat your first meal? When do you eat your last?
How much water do you drink each day?
How much other beverages? Select all that apply:
Coffee
Soda
Tea
Alcohol
How many times a week do you eat out?
Do you snack between meals?
How would you rate your stress level on a scale 1-10?
Describe WHY you are interested in getting healthy
Have you tried to lose weight before?
Occupation?
Do you enjoy what you do?
Signature
Preview PDF
Submit
Should be Empty: