Coach Kristin's Health Assessment

Health Consult Form

There is no judgement here...HONEST! ...these questions are to better understand and get to know YOU!
Please complete this form to schedule a free health assessment
Name*

First NameLast Name
Contact Number*
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred method of contact*

CallTextEmail
How did you hear about our program?*
If you were referred, name of person who referred you.
When you live with purpose, every step toward health becomes a vicotry, not a chore!

Now let's talk about your dreams, wishes, desires!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)*
Describe where you would like to be in your Health..*
Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.) Be specific!*
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?*
Medical
Medical Conditions/Allergies
Do you have any medical conditions or allergies?
If yes, please specify:
Are you currently pregnant or breastfeeding ?*

PregnantBreastfeedingNo
Are you taking medications for:*

DiabetesThyroid**High Blood PressureLithium*High CholesterolBlood Thinners (Coumadin, Warfarin)***
Are you taking other medications or have other medical conditions that could influence which program we choose?*
*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.
Sleep
What time do you typically go to bed?
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep?
Do you wake feeling rested?
Hydration
How much water do you drink a day in ounces?
How many cups of coffee/tea do you have daily?
How many energy drinks do you have in a week?
How often do you consume alcohol?
Movement
How would you rate your energy level?
Describe your activity level... what type of physical activities do you participate in?
What are things you can NOT do that you would LIKE to do?
Stress
How do you rate your stress level?
What do you do for work?
How much do you like what you do?
What are the main stresses in your life?
Eating Habits
How many meals do you eat daily?
When is your first meal?
When is your last meal?
Do you snack during the day?
What type of snacks?
How many times do you eat out?
Where do you eat out at?
Weight
Current weight
Desired weight
Height
Have you tried losing weight before and/or eating healthy?
What have you tried in the past?*
What has been most difficult about losing/maintaining weight in the past?*
How would you describe the people you spend time with regularly? (active and health focused, supportive but not necessarily focused on health, I tend to hang out with people who are not focused on health or have unhealthy habits)
Is there anyone in your life who you think would enjoy joining you on this health journey?
Thank you so much.

I am looking forward to speaking with you!!

CLICK THE LINK BELOW TO SUBMIT & I WILL BE IN TOUCH WITHIN 24 HRS
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Health Consult Form

Medical

Sleep

Hydration

Movement

Stress

Eating Habits

Weight