HEALTH EVALUATION

Your Information:

Please fill out as much as you can under each section, especially if you have particular medical or health issues. Not all the fields are required. This will help me know how best to assist you in your journey to Optimal Health. Your best days are ahead!
Name*
Phone*
Format: (000) 000-0000.
Email*
Preferred Method of Contact*
Address*

Street Address

CityState / 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. *
2. What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc*
3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?*
4. Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?*
NoYes
NoYes
DiabetesHigh Blood PressureLithium*ThyroidCoumadin (Warfarin)Medically Supported Weight Loss MedicationOther
High Blood PressureDiabetes - Type 1Diabetes - Type 2GoutGluten Allergy or IntoleranceSoy Allergy or IntoleranceFood 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?*
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?*
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)*
What types of physical activity do you enjoy?
MIND
On a scale of 1-10, how fulfilled are you?*
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?*
On a scale of 1-10, how much do you enjoy what you do?*
FOOD & HYDRATION
How many meals and snacks do you eat per day?*
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?*
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*
Height*
How much do you currently weigh?*
What would you consider to be a healthy weight for you?*
Have you tried to lose weight in the past?*
What has been difficult for you about losing and maintaining weight?*
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*
Is there anyone in your life who would like to get healthy with you?*
Is there anything else you think I should know about your health?*
Should be Empty:

Your Information:

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS