Health Assessment
Fill out my health assessment below, so together we can get you started on a health & fitness journey that's right for YOU!
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Current Weight
*
kg
Current Height
*
cm
Current illnesses/health issues.
*
Current Medications/supplements.
*
Are you currently a coach or working with a coach?
Please Select
Yes
No
If you knew failure wasn't an option, where would you like to be in 3 months? Think physically, mentally, emotionally, life goals, etc.
Have you got a specific goal in mind in terms of physique/weight/lifestyle/nutrition/fitness? If so- please describe.
*
What are your health & fitness struggles currently? (E.g. areas such as lack of time, digestion, energy level/fatigue, food intake, weight loss/gain, hormonal imbalances, blood pressure management, pain, inflammation, bloating, emotional instability etc.)
Please rate your energy levels:(1 - you can't get out of bed. 10 - thriving energy all day.)
*
1
2
3
4
5
6
7
8
9
10
Please elaborate if necessary.
Please rate your digestive health:(1 - Poor. 10 - Amazing.)
*
1
2
3
4
5
6
7
8
9
10
Please elaborate if necessary.
How regular are your bowel movements?
1-3 times a week
Every other day
Every day
How would you rate your overall health? 1- I'm constantly sick and can barely function, 10- I feel completely amazing and don't feel like I need to make any adjustments.
*
1
2
3
4
5
6
7
8
9
10
Please best describe your overall mood throughout the week.
Rate your sleep. 1-horrible 4 -fantastic.
1
2
3
4
Please elaborate on sleep- Do you have a set bed time? What is it? What time do you wake up? Do you have a watch that tracks deep sleep? Do you wake up feeling refreshed?
What are your biggest barriers to reaching your goals, why have you not been successful in the past?
Give me a glimpse into your nutrition in a day! What do you eat, when and how much. Are you a stress eater? Chronic dieter? Do you feel guilty when you splurge? How is your self control? Any previous eating disorders?
What drinks do you consume in a week including quantities? Include alcohol, soft drinks/soda, tea coffee etc.
e.g. one soda per day, 3 coffees a day, 4 alcoholic beverages on the weekend.
How much water do you drink in a day?
Rough total
What is your current fitness level?
I do zero physical activity
Somewhat fit
Fit
Tell me about your current fitness regime. Walking/number of steps, gym, strength, cardio? Amounts and types.
What is your current occupations? How active are you throughout a typical day? Eg nurse versus a desk job.
Would you like input on your fitness regime/goals?
No thanks
Unsure for now
Yes please
Anything else you would like me to know about you?
Save
Submit
Should be Empty: