Health Assessment Form
The first step in your lifelong transformation
Name
*
First Name
Last Name
Email
*
example@example.com
What's the best number to contact you to go over your results?
*
Include extension
From what source did you access this assessment?
*
Facebook group
Instagram
Referral
Sent to me personally
Other
What you would like to accomplish with your health (Weight loss, improved sleep, improved mental health, personal development, etc.)?
*
What is your primary motivation for wanting to make changes to your health (Relationships with yourself and others, activities, how you feel, Longevity, Free from disease, etc.)?
*
What activities would you like to do that you don’t do right now?
*
How do you spend your free time?
Do you have a strong community of support?
Yes
No
Some support but I would like more
What would it mean to you to be at a healthy weight and wake up every day excited and full of energy?
Are you taking medication for any of the following or any of the following medications:
*
Diabetes
High Blood Pressure
Cholesterol
Thyroid
Lithium
Coumadin (Warfarin)
Antidepressants or Anxiety meds
None
Other
Do you suffer from any of the following?
*
High Blood Pressure
Type I Diabetes
Type II Diabetes
Gout
None
Other
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Do you have any of the following allergies:
*
Gluten
Soy
Eggs
Dairy
Nuts
None
Other
Age
Height
Although your health is about a lot more than the number on the scale, if you could wave a magic wand and lose whatever you wanted to how much would you lose?
How many years has it been since you were at your goal weight?
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Daily Habits
What are you currently doing for self-care? (Meditation, personal development, having a morning or evening routine, etc.)
How many hours of sleep do you get in a typical night?
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Over 8 hours
6-7 hours
Less than 6 hours
How would you rate the quality of your sleep?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How many days a week do you exercise?
None
1-3 days
More than 3 days
What type of physical activity do you enjoy?
How would you rate your energy level?How would you rate your energy level?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How would you rate your stress level?How would you rate your stress level?
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Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How many meals do you eat per day?
*
How many snacks do you eat per day?
*
What type of snacks do you enjoy?
How many ounces of water do you drink per day?
*
How many times do you eat out per week? (Including Fast Food)
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1-2
3-4
Daily
Never
Typically people spend between $15-$20 a day on food. How much do you believe you spend?
*
Can you identify any unhealthy patterns in your eating habits? (Midnight snacking, stress eating, eating out of boredom, etc.)
How committed are you to making a change in your health?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How coachable are you?How coachable are you?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
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Healthy Finances
Financially speaking I am...
*
Very comfortable
Have enough to meet my needs
Feel strapped
Concerned about making ends meet
Would rather not answer
My current employment is...
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Very fulfilling
Pays the bills, but I don’t love it
Can’t quite make ends meet
Homemaker
In between jobs
Retired
Would you be interested in learning more about helping others and building a community around you?
*
Yes, very!
I am curious.
Maybe, not sure.
Not at this time
When is the best time to contact you?
*
Mornings
Afternoon
Evening
Weekend
Submit
Should be Empty: