Free Online Health Assessment Form
The following questionnaire is a comprehensive look at your health. It will take about 5 minutes to complete. Once completed, we will contact you to schedule a free phone consultation to find the program that would be the best fit for you and your health goals.
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Prefer not to answer
E-mail
example@example.com
Phone Number
*
Format: (000) 000-0000.
Time Zone
Name used on Social Media
Name used on social media accounts
Who referred you to me? Enter N/A if not applicable.
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Begin
GENERAL HEALTH INFORMATION
What would you like to accomplish in your health
*
Lose weight
Manage chronic conditions (diabetes, high cholesterol, etc)
Gain weight
Build muscle
Improve sleep
Gain energy
Learn healthy habits
Reduce inflamation
Other
If weight loss is a goal, how much would you choose to lose (if you could not fail)?
Do you have any of these health conditions?
Type 1 diabetes
Type 2 diabetes
High blood pressure
Low blood pressure
Hypothyroidism
Hyperthyroidism
Gout
Cancer
Anxiety
Depression
Other
Do you take any of the following?
Thyroid medication
Coumadin (Warfarin)
Lithium
Multivitamin
Probiotics
Diuretics
Medications for diabetes
Medications for high blood pressure
Weight loss medications
Other
Do you have any of the following allergies, sensitivities, or dietary considerations
Gluten allergies/intolerance
Soy allergies/intolerance
Vegetarian
Lactose allergies/intolerance
Pescatarian
Kosher
Vegan
Other
Are you pregnant or nursing
*
Please Select
Neither
Pregnant
Nursing
Pregnant & nursing
Trying to get pregnant
Not applicable
Do you have any other allergies or medical considerations that should be taken into account when customizing a plan for you?
Age
*
Current Weight
Height
Feet and Inches (i.e. 5' 7")
The following three questions: 1 - 10 (1=low / 10=high)
How do you rate your current level of energy?
*
1 - What energy?
2
3 - Below average
4
5 - About Average
6
7
8 - Above average
9
10 - I have non-stop energy!
How do you rate your average stress levels?
1 - I have no stress at all
2
3 - Below average stress
4
5 - About average
6
7
8 - Above average stress
9
10 - I am stressed all the time
How many hours sleep do you get a night?
*
Do you have trouble getting to sleep?
Please Select
No
Yes
Occasionally
Do you wake often, or get woken easily?
Please Select
No
Yes
Occasionally
Do you snore or have breathing problems during sleep?
Please Select
Yes
No
Not sure
Additional info you might want to share
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Next
DIET & LIFESTYLE
Do you exercise?
*
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
How long do you usually exercise for?
*
10-20 minutes
21-35 minutes
36-50 minutes
51+ minutes
Not applicable
Please list the types of exercise you do regularly
How many ounces of water do you drink in a day?
*
What do you drink other than water?
Coffee
Tea
Soda
Diet Soda
Beer
Wine
Other Alcohol
Other
How much do you spend on all beverages in a month?
How often do you eat out?
1-2 times per month
3-5 times per month
6-10 times per month
Less than once per month
More than 11 times per month
Never
What types of food do you eat out?
How much do you spend eating out per month?
Average is $10-$15 per meal eating out.
About how much do you spend a month on groceries for yourself?
*
According to the 2020 census, the average American spends $420 a month on personal food & drink options.
On a scale of 1-10, how happy are you with your current health?
Please Select
1 - not happy
2
3
4
5
6
7
8
9
10 - extremely happy
On a scale of 1-10, how much do you worry about your health?
Please Select
1 - Never
2
3
4
5
6
7
8
9
10 - All the Time
What area of your life causes the most stress for you?
What do you do for work?
On average, do you consider your lifestyle sedentary, moderate, or active?
Please Select
Sedentary
Moderate
Active
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