Health Assessment

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 NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Are you currently a coach or working with a coach?
GOALS: If you could get to your dream results in a instant, what would life look like? How does that differ from now?
Do you have any health conditions to take into account? (Thyroid, diabetes, etc.)
Lithium: Healthcare providers may wish to adjust frequency of lab work for client and monitor. Thyroid: Healthcare provider may wish to monitor thyroid levels while on program and adjust as needed. Coumadin (Warfarin): Healthcare provider may wish to review food choices and conduct lab work and/or adjust monitoring.
Please rate your energy levels:(1 - you can't get out of bed. 10 - thriving energy all day.)
What physical activities do you participate in? How many days per week?
Are there physical things you can’t do that you would like to do in the future? I.E. playing with kids/grandkids.
Upon submitting this form, you will be directed to schedule a quick health assessment debrief with me. If we have not already set a time to chat, you can request an appointment via call or zoom to discuss which program is right for you. Your future healthy you awaits!
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