Health Assessment With Renee
Fill in the form below so we can best assess your wellness needs
Name
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First Name
Last Name
Date Of Birth
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-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
How Did You Hear About Us?
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I would love to hear what you would like to accomplish with your health (Weigh Loss, improved sleep, better response to stress etc.)
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What is your main motivation for wanting to make a change to your health? (Relationships, activities, how you feel about yourself etc.)
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Can you tell me about a time in your life when you were healthier? What has changed between then and now?
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Tell me about your Health: Do you have any allergies or medical conditions that could influence which Program we choose?
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Are You Pregnant?
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Please Select
Yes
No
Are you nursing?
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Please Select
Yes
No
If you are nursing how old is your child?
Are you taking any medications for:
Diabetes
High Blood Pressure
Lithium
Thyroid
Coumadin (Warfarin)
Other Medications
Please List All Supplements & Medications:
Do you have the following
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High Blood Pressure
Diabetes Type 1
Diabetes Type 2
Gout
Gluten Intolerance or Sensitivity
Soy Allergy or Intolerance
Food Allergies
Other
NO MEDICAL CONDITIONS
How many hours of sleep do you get in a typical night?
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How would you describe the quality of sleep?
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On a scale 0-10, what is your energy level throughout the day?
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How would describe the quantity & quality of the activity you do each week?
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How many hours a day do you sit?
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How many days a week do you exercise
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What types of physical activity do you enjoy?
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On a scale of 1-10, how fulfilled are you?
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On a scale 1-10, how much do you worry?
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What area of your life tends to be the biggest stress for you?
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What do you do for work?
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On a scale of 1-10, how much do you enjoy what you do?
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How many meals and snacks do you eat per day?
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When do you eat your first meal of the day?
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How many times a week do you eat out & where?
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How many ounces of water do you drink per day?
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Do you drink other beverages? Coffee, soda, alcohol, tea etc. IF so how often?
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Are you comfortable sharing your age?
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How tall are you?
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Current weight:
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What do you consider a healthy weight for you?
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Have you tried to lose weight in the past? What has been difficult for you about losing weight and maintaining your goal weight?
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On a scale of 1-10, how health would you rate your surroundings?
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Do you feel you have a good support team to help you lose weight?
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Is there anyone else you want to get healthy with?
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Is there anything else you would like to share with me?
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