Lifestyle Nutrition-Health Evaluation
5-10 Minute Evaluation-Once submitted we will contact you within 24 hours. Questions? Call or Text 314-649-7877
Name
*
Phone
*
Email
*
Preferred Method of Contact
*
Address
*
Street Address
City
State / Province
Postal / Zip Code
Referred From?
STEP 1: AWAKEN
1. What would you like to accomplish with your health? This could be weight-loss, improved sleep, better response to stress, etc.
*
2. What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
*
3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?
*
4. Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?
*
5a. Are you Pregnant?
No
Yes
5b. Are you Nursing?
No
Yes
6. Are you taking any medication for:
Diabetes
High Blood Pressure
Lithium*
Thyroid
Coumadin (Warfarin)
Other
7. Do you have any of the following:
High Blood Pressure
Diabetes - Type 1
Diabetes - Type 2
Gout
Gluten Allergy or Intolerance
Soy Allergy or Intolerance
Food Allergy (Medically Diagnosed)
Other
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the Client and monitor. Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication. Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
STEP 2: DAILY ROUTINE & HABITS
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
How would you describe the quantity & quality of the activity you do each week?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
*
What types of physical activity do you enjoy?
MIND
On a scale of 1-10, how fulfilled are you?
*
On a scale of 1-10, how much do you worry?
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?
*
FOOD & HYDRATION
How many meals and snacks do you eat per day?
*
When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
*
Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
WEIGHT MANAGEMENT
Age
*
Height
*
How much do you currently weigh?
*
What would you consider to be a healthy weight for you?
*
Have you tried to lose weight in the past?
*
What has been difficult for you about losing and maintaining weight?
*
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, keep junk food in the house, etc
*
Is there anyone in your life who would like to get healthy with you?
*
Is there anything else you think I should know about your health?
*
Submit
Should be Empty: