HEALTH ASSESSMENT-client copy

HEALTH ASSESSMENT

30 Days to Healthy Living
Name
Email
example@example.com
Date

MonthDayYear
Today's Date
Address
City
State
Two Letter Abreviation
Zip Code
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
How did you hear about our program?
If you were referred, name of person who referred you.
Preferred Method Of Contact
Awaken...Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)

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Describe where you would like to be in your Health...

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Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)

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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)?

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Are there any food or other allergies that I should be aware of?

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SLEEP
How many hours of sleep do you typically get?
What time do you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much Coffee?
How much Soda?
How much Tea?
How much Alcohol?

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MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
STRESS
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
EATING HABITS
How many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Where?
WEIGHT
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?

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SURROUNDINGS
How healthy would you rate your surroundings? (on a scale of 1-10)
Is there anyone in your life who would like to get healthy with you?
Should be Empty: