Tenacity Health Wellness Survey

Tenacity Health Wellness Survey

Helping others reach their goals and develop health for generations!
Name*

First NameLast Name
Date*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Who referred you to me?
If you were referred, or you saw someone's social media post, enter their name here.
CallTextEmail
Describe where you are in your health now (weight, sleep, stress, energy, etc.)*
Describe WHY you are interested in getting healthy. What is your main motivation: relationships, activities, how you feel, etc.*
Background
Diabetes - Type 1Diabetes - Type 2High blood pressureGoutFamily history of 1 or more
DiabetesHigh blood pressureHigh cholesterolThyroid**Lithium*Coumadin (Warfarin)***
Are you taking other medications or do you have other medical conditions that could influence which program we choose?
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
Hydration

For each of the following beverages, please enter the amount you drink each day in ounces.
Water*
Coffee*
Soda*
Tea*
Energy Drinks*
Alcohol (per week)*
Motion
How would you rate your energy level?
0=No energy at all; 10=Toddler on a sugar high
Do you exercise? (times per week)*
Include any healthy motion
Are there things you would like to do that you are currently unable to?*
Stress
How would you rate your stress level?*

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
What is your job title? Describe what your day looks like.*
What types of things do you enjoy doing?*
Are there any other stressors in your life?
Eating Habits
How many meals per day do you typically eat?*
YesNo
What do you snack on? Do you keep comfort type foods in the house?*
How many times a week do you eat out?*
Fast foodSit-downA little of both
Weight
Current Weight
Goal Weight
Height
YesNo
Surroundings
How healthy would you rate your surroundings?

1

2

3

4

5

6

7

8

9

10

1 is Very Healthy, 10 is Very Unhealthy
Is there anyone in your life who would like to get healthy with you and why?
Do you have healthy & active friends... supportive family?
How ready are you to reach your goals and take your health in a positive direction?

1

2

3

4

5

6

7

8

9

10

1 is Unsure , 10 is Beyond Ready
Thank you for taking the time to share! I look forward to talking soon!
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Tenacity Health Wellness Survey

Background

Hydration

Motion

Stress

Eating Habits

Weight

Surroundings

Thank you for taking the time to share! I look forward to talking soon!