Health Survey

Health Survey

Help me get to know you so I can serve you better
Name

First NameLast Name
Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contacts

Phone CallEmailPhone MessageOther
Birth Date (just for a free birthday gift)

MonthDayYear
Age
Ex:23
Gender
Medical
Do you have any of the following?

Diabetes - Type 1Diabetes - Type 2Digestive IssuesHigh Blood PressureHigh CholesterolArthritisExcessive WeightOther
Are you taking any medications for

DiabetesThyroidHigh Blood PressureLithiumHigh cholesterolCoumadin (Warfarin)InflammationOther
Please describe
Sleep
How many hours do you sleep?

Less than 5 hours5 - 6 hours7 - 8 hours9 - 10 hoursMore than 10 hours
Do you wake up feeling rested?

YesNoOther
Hydration
In a day, how much water do you drink usually?
In a day, how much coffee do you drink usually?
In a week, how much alcohol do you consume usually?
Movement
Do you do any exercise?

1 - 3 a week3 - 5 a weekEverydayNever
How would you rate your daily energy level?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Stress
Rate your overall stress level

1

2

3

4

5

1 is Lowest, 5 is Highest
Eating Habits
When do you eat your first meal?
When do you eat your last meal?
How many meals per day do you eat?
Do you snack? If yes, what do you snack on?
How often do you eat out in a week?

AlwaysUsuallySometimesRarelyNeverOther
Weight
Current Weight
Goal Weight
Height
Have you tried to lose weight before?

YesNo
What have you found to be the most difficult part of losing weight in the past?
Describe where you would like to be in your health:
Thank You! We will contact you shortly.
Should be Empty:

Health Survey

Medical

Sleep

Hydration

Movement

Stress

Eating Habits

Weight