Saratoga Wellness Health Evaluation Form

Saratoga Wellness Health Evaluation Form
DATE

MonthDayYear
Date
GENDER
NAME
AGE
PHONE
Format: (000) 000-0000.
WEIGHT
HEIGHT
EMAIL
example@example.com
IDEAL WEIGHT
SESSION FOCUS
Top 3 Client Priorities
DIAGNOSES & HEALTH CHALLENGES
MAJOR HEALTH EVENTS
DIGESTIVE SYMPTOMS
Other
BOWEL MOVEMENTS
DISRUPTIVE FOODS
ALLERGIES & SENSITIVITIES
STRESS LEVEL
SOURCES
MANAGEMENT
SUPPORT SYSTEM
MOVEMENT
SLEEP
AVG HOURS
QUALITY
CHALLENGES
HYGIENE
WATER INTAKE
WATER SOURCE
IDEAL INTAKE
CAFFEINE INTAKE
CAFFEINE SOURCE
ALCOHOL INTAKE
OTH BEVERAGES
SMOKING
MEDICATIONS
SUPPLEMENTS
DIET
TYPICAL FOODS
TIMING
SNACKING
OILS & FATS
QUALITY
TOP HEALTHY FOODS
TOP UNHEALTHY FOODS
SWEETS
CRAVINGS
LIFESTYLE
DIET
SUPPLEMENTS
HANDOUTS
FOLLOW UP PLAN
DATE

MonthDayYear
Date
SESSION FOCUS
FOLLOW-UP NOTES
Recommendations
DATE

MonthDayYear
Date
LIFESTYLE
Hydration Goal:
FOODS TO ADD
Supplements (Recommendations)
Nutritional Protocol
NAME
DATE

MonthDayYear
Date
Supplement (Dose, Frequency, Timing, Notes)
Supplement (Dose, Frequency, Timing, Notes)
Supplement (Dose, Frequency, Timing, Notes)
Supplement (Dose, Frequency, Timing, Notes)
Supplement (Dose, Frequency, Timing, Notes)
Diet & Lifestyle + Notes
Diet & Lifestyle + Notes
Diet & Lifestyle + Notes
Diet & Lifestyle + Notes
prayer/meditation:
detachment:
reading:
other:
technology:
learning:
relationships:
other:
whole food diet:
hydration:
movement:
other:
SOUL
spiritual health
MIND
mental health
BODY
physical health
SARATOGA WELLNESS PLLC NP IN PSYCHIATRY
"MENS SANA IN CORPORE SANO"

"HEALTHY MILD IN A HEALTHY & BODY"

www.saratogapsychiatricwellness.com.
Should be Empty:

Saratoga Wellness Health Evaluation Form

SLEEP

DIET

Recommendations

Nutritional Protocol