Optavia Health Assessment

HEALTH ASSESSMENT

Dr. Liz Lyster
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Birth Date

MonthDayYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Format: (000) 000-0000.
Awaken... Discover where you are and where you want to be!
Describe where you are in your Health now... (weight, sleep, stress, energy, etc.)*
Describe where you would like to be in your Health...*
Please describe WHY you are interested in getting healthy (what is your main motivation.. relationships, activities, how you feel, etc.)*
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?*
MEDICAL
YesNo
YesNo
DiabetesHigh Blood PressureGout
Any Food Allergies that I should be aware of?
Please list any medications you are currently taking
SLEEP
How many hours of sleep do you typically get each night?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much coffee do you drink each day?
How much alcohol do you drink each day?
MOTION
How would you rate your energy level? (On a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to do?
STRESS
How would you rate your stress level? (On a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
Are there any other stressors in your life?
EATING HABITS
How many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack in between meals?
If yes, what kind of snacks?
How many times a week do you eat out, and where do you go?
WEIGHT
Current weight
Goal weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
SURROUNDINGS
How healthy would you rate your surroundings? (On a scale of 1-10)
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?
Should be Empty:

HEALTH ASSESSMENT

Awaken... Discover where you are and where you want to be!

MEDICAL

SLEEP

HYDRATION

MOTION

STRESS

EATING HABITS

WEIGHT

SURROUNDINGS