Dani Bishop

Health Assessment

Healthy Living by Dani
Name

First NameLast Name
Address

Street Address

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CityState / Province

Postal / Zip Code
Phone Number

Phone Number
Email
example@example.com
Date

MonthDayYear
Date
How did you hear about our programs?
Please describe your WHY to becoming a healthier version of yourself. (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 is part of your goal)
Medical Questions
Are you pregnant?
Are you nursing?
If yes, how old is your baby?
Do you have any of the following?
Do you have any food allergies or dietary restrictions?
Are you taking any medications for:
Please list additional medications or supplements you are taking, and what you may be specifically taking them for
Sleep
How many hours of sleep do you typically get per night?
What time do you typically wake up?
Do you feel run down or dragging throughout the day?
Hydration
How many ounces of plain water do you typically drink per day?
Do you consume any other beverages?
Motion
Do you currently exercise? If so, how many times a week?
What physical activities do you participate in?
How would you describe your daily activity level?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How soon after waking up do you eat something?
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
Do you have a snack before bedtime? If so, what?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc.)
Weight
Current Weight: (if you wish to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
What has been the most difficult thing about losing weight in the past?
Email: healthylivingbydani@gmail.com

Cell: 931-444-0247

Facebook: https://www.facebook.com/danielle.lynn.165
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Health Assessment

Medical Questions

Sleep

Hydration

Motion

Stress

Eating Habits

Weight