Amanda Vasquez
My passion is to help everyone reach their Optimal Health one Healthy Habit at a time!
Health Evaluation
Please fill out as much of the following as you can, particularly if you have any medical conditions requiring medication, food allergies or dietary restrictions. This will help us know how to best assist you. I look forward to getting to know you!
Name
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Phone
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Format: (000) 000-0000.
Email
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Preferred Method of Contact
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Address
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Street Address
City
State / Province
Postal / Zip Code
Referred From?
STEP 1: AWAKEN
1. What would you like to accomplish with your health? This could be weight-loss, improved sleep, better response to stress, etc.
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2. What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
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3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?
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4. Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?
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5a. Are you Pregnant?
No
Yes
5b. Are you Nursing?
No
Yes
6. Are you taking any medication for:
Diabetes
High Blood Pressure
Lithium*
Thyroid
Coumadin (Warfarin)
Medically Supported Weight Loss Medication
Other
7. Do you have any of the following:
High Blood Pressure
Diabetes - Type 1
Diabetes - Type 2
Gout
Gluten Allergy or Intolerance
Soy Allergy or Intolerance
Food Allergy (Medically Diagnosed)
Other
*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.
STEP 2: DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
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How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
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MOTION
How would you describe the quantity & quality of the activity you do each week?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
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What types of physical activity do you enjoy?
MIND
On a scale of 1-10, how fulfilled are you?
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On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?
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On a scale of 1-10, how much do you enjoy what you do?
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FOOD & HYDRATION
How many meals and snacks do you eat per day?
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When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
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Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
The average person spends $15-$25 day on food and drink. How much do you think you spend?
WEIGHT MANAGEMENT
Age
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Height
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How much do you currently weigh?
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What would you consider to be a healthy weight for you?
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Have you tried to lose weight in the past?
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What has been difficult for you about losing and maintaining weight?
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SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, keep junk food in the house, etc
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Is there anyone in your life who would like to get healthy with you?
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Is there anything else you think I should know about your health?
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