Online Health Evaluation

Online Health Evaluation

Russ & Denise McCann, Certified Health Coaches since 2007
Take a few minutes to identify your ideal health goals and what it is you are looking to achieve. As you enter this information, reflect on how your life will change once you reach your longterm goals. Getting clear on where you are right now in your health and what you would like to create long-term will be life changing!

"We are excited to help you create a healthier life, one healthy habit at a time!"
Today's Date

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Full Name*
Cell Phone Number:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
HEALTH GOALS - CREATING A HEALTHIER YOU
If you could not fail: What would you like to create in your health, and what are your short-term and long-term health goals? Where are you now in your health, and what will it take for you to take back your health and your life? Example: Lose Weight, feel better, fit in clothes, reduce pain, have more energy, make permanent changes, stop yo-yo dieting, etc...*
ACTIVITIES AND OPTIMAL HEALTH
Why is it important to lose weight, and what activities will you include in your journey to Optimal Health? Whether it's hiking, biking, kayaking, gardening, playing with the kids/grandkids, or gym workouts, choose activities you enjoy.*
THE FUTURE YOU - DREAM
Imagine that you have reached your ultimate health goals! What will your healthier YOU look like? What are you now able to do, how do you feel, what does your new daily routine look like, and how has your life changed as you continue your journey toward Optimal Health and Well-being? (Be creative and dream)*
MEDICAL HEALTH HISTORY

All information provided is kept private
Are You Pregnant

NoYesCurrently Nursing
Do you have any of the following conditions or medical concerns?

High Blood PressureHigh CholesterolDiabetes - Type IDiabetes - Type II/PreDiabetesGoutGluten Intolerance or SensitivitySoy Allergy or IntoleranceFood Allergies
Tell us about any food allergies, digestive conditions, or any previous weight loss surgeries:
Are you taking any medications for the following medical conditions:*

Diabetes (Metformin, Insulin, ...)Weight Loss GLP-1 (Ozempic, etc)High Blood Pressure MedsHigh Cholesterol MedsLithiumThyroid MedsCoumadin (Warfarin)Other Medications that might affect weight loss? * (Comment Below)Vitamins and SupplementsNot taking any medications at this time
* List any other medications that might affect your weight loss
INITIAL WEIGHT LOSS GOALS & HEALTH STATS
Gender
Current Age*
Height*
Current Weight*
DESIRED ULTIMATE GOAL WEIGHT*
STEP 2: TYPICAL DAILY ROUTINE
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?*
MOTION
How would you describe your current activity level? (Sedentary, Moderate, High)*
What type of activity do you enjoy most (Gym, Walking, Gardening, Pickleball, etc..)*
MIND
What area of your life tends to be the biggest stress for you?*
What do you do for work?*
Do you feel you have meaning and purpose in your life?*
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 regularly? (Coffee, Tea, Juice, Soda, Alcohol).
How much do you think you spend per day on food, beverages, snacks, and treats? (Include Starbucks, Fast Food, Meals Out, Candy, Soda, Alcohol, Groceries, Snacks/Treats, etc... (On average, most Americans spend between $18-$35 per day)*
WEIGHT MANAGEMENT
What would you consider to be a healthy weight for you?*
Have you tried to lose weight in the past? If so, what plans or programs have you tried?*
What has been difficult for you about losing and maintaining weight?*
On a scale of 1-10, how healthy would you rate your surroundings? Things to consider: (Your environment at home and work: Are you surrounded by supportive people or are there lots of temptations? Are there positive or negative people in your day-to-day life?)
SURROUNDINGS & SUPPORT SYSTEM
Is there anyone in your life who would like to get healthy with you?
Are there any additional details about your health and well-being that would be beneficial for us to know as we embark on this journey to enhance your overall health and life?
On a scale of 1-10, how motivated are you to take control over your daily routine to create long-term Optimal Health? (10 being highly motivated & 1 not motivated at all)
Should be Empty:

HEALTH GOALS - CREATING A HEALTHIER YOU

ACTIVITIES AND OPTIMAL HEALTH

THE FUTURE YOU - DREAM

MEDICAL HEALTH HISTORY

INITIAL WEIGHT LOSS GOALS & HEALTH STATS

STEP 2: TYPICAL DAILY ROUTINE

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS & SUPPORT SYSTEM