Health Assessment

Thank you so much for reaching out!

My desire is to walk along side you as you create simple, sustainable habits that will help you reach your health goals. YOU'VE GOT THIS!
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Name

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Address

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Postal / Zip Code
How did you hear about our program?
If you were referred, please put the name of the person who referred you OR where you saw this link.
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CURRENT HEALTH ASSESSMENT

This section will give me a better idea of your currently in your health.
What is your current age?
How tall are you?
How much do you currently weigh?
Do any of the following apply to you? (select all that apply)

Other
Are you pregnant?
Are you nursing?
SITUATIONAL HEALTH: Are there situations or factors making your life difficult right now that could hinder you from prioritizing your health? (What feels out of control right now?)
Have you tried to reach certain health goals in the past? If so, what have you tried?
STRESS: Describe your most common sources of worry or stress. How do they affect your daily life?
PERSONAL REFLECTION: In one sentence, how would you describe your current relationship with your health?
Are there things you can't do that you would like to do? What are those things?
SLEEP HABITS
How many hours of sleep do you get on average each night?
How would you rate the quality of your sleep on a scale of 1 to 10?

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10

1 is HORRIBLE, 10 is EXCELLENT
FOOD AND SPENDING HABITS
What does a typical day of eating look like for you? (This includes beverages - Starbucks, alcohol, anything that goes in your mouth. Please include when you have your first meal of the day and how many times you eat throughout the day.)
On average, how much do you spend on food and beverage each day?
HYDRATION
How much water do you drink daily?
How much alcohol/soda/sweet tea weekly or monthly do you consume? What are your drinks of choice?
ENERGY LEVELS
On a scale of 1 to 10, how would you rate your average energy level throughout the day?

NOT GOOD GREAT
EXERCISE AND MOVEMENT

If you aren't currently moving your body...don't freak out!
Describe the type and intensity of the healthy motion you typically do. (If you don't currently move your body, that's OK! If you are currently incorporating healthy motion into your week, please let me know how many times per week.)
HEALTH GOALS

This section will give me a better idea of what you are looking to accomplish with your health.
What would you like to accomplish with your health (select all that apply)?
VISION: If you could describe your optimal health in one sentence, what would it be? Why is achieving this vision important to you? Dive deep and think about how it would change your daily life and long-term future.
COMMITMENT
COMMITMENT LEVEL: On a scale of 1-10, how committed are you to making lasting changes in your health?

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10

1 is NOT SO SURE, 10 is FULL STEAM AHEAD
FINAL REFLECTION: Imagine it's a year from now, and you've made significant progress in your health journey. What do you think made the biggest difference?
Additional comments you want me to know:
Should be Empty:

Thank you so much for reaching out!

CURRENT HEALTH ASSESSMENT

SLEEP HABITS

FOOD AND SPENDING HABITS

HYDRATION

ENERGY LEVELS

EXERCISE AND MOVEMENT

HEALTH GOALS

COMMITMENT