Health Assessment With Renee

Health Assessment With Renee

Fill in the form below so we can best assess your wellness needs
Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How Did You Hear About Us?*
I would love to hear what you would like to accomplish with your health (Weigh Loss, improved sleep, better response to stress etc.)*
What is your main motivation for wanting to make a change to your health? (Relationships, activities, how you feel about yourself etc.)*
Can you tell me about a time in your life when you were healthier? What has changed between then and now?*
Tell me about your Health: Do you have any allergies or medical conditions that could influence which Program we choose?*
Are You Pregnant?*
Are you nursing?*
If you are nursing how old is your child?
Are you taking any medications for:

DiabetesHigh Blood PressureLithiumThyroidCoumadin (Warfarin)Other Medications
Please List All Supplements & Medications:
Do you have the following*

High Blood PressureDiabetes Type 1Diabetes Type 2GoutGluten Intolerance or SensitivitySoy Allergy or IntoleranceFood AllergiesOtherNO MEDICAL CONDITIONS
How many hours of sleep do you get in a typical night?*
How would you describe the quality of sleep?*
On a scale 0-10, what is your energy level throughout the day?*
How would 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*
What types of physical activity do you enjoy?*
On a scale of 1-10, how fulfilled are you?*
On a scale 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?*
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 & 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?*
Are you comfortable sharing your age?*
How tall are you?*
Current weight:*
What do you consider a healthy weight for you?*
Have you tried to lose weight in the past? What has been difficult for you about losing weight and maintaining your goal weight?*
On a scale of 1-10, how health would you rate your surroundings? *
Do you feel you have a good support team to help you lose weight?*
Is there anyone else you want to get healthy with?*
Is there anything else you would like to share with me?*
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