Confidential Personal Wellness Assessment

Full Name

First NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

example@example.com

Cell Phone

Area CodePhone Number

Any Allergies

Weight

Height

Gender

Will you be using your insurance to cover the medication?

if yes, provide insurance carrier name

if yes provide insurance member ID# Group # and RXbin#

insurance information

How will you be checking in?

How did you hear about this program?

What are your top 3 goals for joining our program?

Are you under the care of a qualified healthcare professional? Please list.

Are you in good health at the present time to the best of your knowledge? Yes No

Do You have a history of any of the following :

Do any immediate family members have a history of any of the following :

What medications, supplements and over the counter items do you take regularly or are currently prescribed: ( list N/A if none)

Any past surgeries and hospitalizations?

What is your line of work or study?

Do you exercise regularly? Please detail.

What kind of other movement or activities do you enjoy?

Do you have problems falling or staying asleep?

How many hours do you sleep?

Do you wake up refreshed?

How is your energy?

Does your energy level affect your daily activities?

How would you describe your mood, generally:

Does your mood affect your daily activities?

How would you describe your stress level?

What are your sources of stress?

How do you manage stress?

Do you have a personal support network?

Do you regularly drink alcoholic beverages?

If yes, how many per week?

Do you smoke tobacco?

Do you use recreational drugs?

How is your appetite?

How many meals per day do you eat?

What is a typical day, in terms of food intake? Please list all meals and snacks.

How much water do you normally drink? Please approximate in ounces.

Please list all types of beverages you regularly drink.

You many times per day do you eliminate? (poop)

Please list any food allergies, intolerance or foods you avoid and the reason.

What past struggles and difficulties have you experienced in terms of food and dieting?

What diet and exercise programs, protocols, plans or approaches have you tried in the past?

What types of diet and exercise approaches have worked for you in the past?

And what hasn't worked for you at all?

Health History

Rows	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
Disordered Eating Pattern/Tendency
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headache
Lightheadednes
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Short of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Blelching/gas
Constipation
Diarrhea
Daily bowel movements

What are your top preferences for checking in?

Rows	Top choice	Works ok	Doesn't work for me
Monday morning (9am-noon)
Monday afternoon (noon-6pm)
Tuesday morning (9am-noon)
Tuesday afternoon (noon-6pm)
Wednesday morning (9am-noon)
Wednesday afternoon (noon-6pm)
Saturday morning (10am-noon)
Saturday afternoon (noon-5pm)

The above are my standard office hours of operation. If none of the above work, please list days and times that would and I will try to work something out with you.

Our goal is to assist you in implementing lifestyle modifications you want to achieve. It is recommended that you seek advice from your medical care professional for your medical needs. Information given through this program is for wellness and educational purposes and is not intended to treat or cure any disease or medical condition. You will seek advice from your medical care professional for your existing medical needs

I understand that all information obtained through this program is for wellness and educational purposes only; that my information is private and will not be sold or shared in any way and that Fitz Six Wellness and associates are not responsible for my medical needs or concerns.

Just one last box to write here anything important that you'd like me to know before we begin.

Confidential Personal Wellness Assessment

General Information

Health History

Personal History

Diet and lifestyle

Let's get a current picture of your health