HEALTH Assessment
Name
*
Last Name
First Name
Date
*
/
Month
/
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
/
Month
/
Day
Year
Date
Preferred Method Of Contact
Text
Call
Email
What would you like to accomplish with your health? (Weight loss, improved sleep, better response to stress, etc)
*
0/100
What is your main motivation for wanting to make changes to your health?(Relationships, activities, how you will feel, etc
*
0/100
Can you tell me about a time in your life when you were healthier?What has changed between then and now?
*
0/100
DAILY ROUTINE & HABITS
How many hours of sleep do you typically get?
What time do you typically go to bed?
What time do you typically wake up?
Quality of Sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
Coffee
Soda
Tea
Alcohol
MOTION
How would you rate your energy level? (on a scale of 1-10)
What physical activities do you participate in?
How many times a week do you exercise?
Are there things you can’t do that you would like to be
STRESS
How would you rate your stress level?
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 last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
What restaurants do you eat at?
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?
*
0/100
SURROUNDINGS
How healthy would you rate your surroundings? (On a scale of 1-10)
Do you have healthy & active friends, supportive family, keep junk food in the house, etc
Is there anyone in your life who would like to get healthy with
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