HEALTH SURVEY
Cecilia Petz - Health Works
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Today's date
Email
*
example@example.com
Address
Street Address
City
State / Province
Postal / Zip Code
Date of Birth
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of contact:
*
Call
Email
Text
Medical
Are you pregnant?
*
Yes
No
If yes, are you nursing?
Yes
No
Do you have any food allergies? If yes, please describe:
Sleep
What time do you usually go to bed at?
What time do you usually wake up at?
How many hours of sleep do you usually get?
*
How is your quality of sleep?
Do you wake up feeling rested?
Hydration
How much water do you drink in a day?
*
How much coffee do you consume in a day?
How much alcohol do you drink in a week?
Movement
How many times a week do you exercise?
What kind of exercise do you participate in?
Are there things you would like to do, that you currently are not physically able to?
How would you rate your daily energy level?
Stress
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
How would you rate your stress level?
Eating Habits
When do you eat your first meal?
*
When do you eat your last meal?
How many meals per day do you eat?
Do you snack? If yes, on what?
How often do you eat out in a week?
Where do you eat out at?
Weight
Current weight:
*
Goal weight:
*
What is your height?
*
Have you tried to lose weight before?
If yes, what have you found most difficult about losing weight in the past?
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Submit
Thank you! I will be in touch with you shortly. You can also email me at ceciliapetzhc@gmail.com
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