Health Assessment for Optavia

Mary Bodnar

Independent Certified Optavia Coach
Your Health Assessment
Name

First NameLast Name
Email
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Date

MonthDayYear
Date
Address

Street Address

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CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
How did you hear about this program?
Describe your current health (weight, sleep, energy, stress, energy etc)
Describe where you'd like to be in your health.
Please describe WHY you are interested in getting healthy. (What is your main motivation: relationships, activities, feelings etc.)
When was the last time you remember feeling your best in your health or being at your ideal weight and size (if that's part of your goal)?
Do you have children? If so, how old are they?
Are there any food allergies I should be aware of?
SLEEP
How many hours of sleep do you typically get?
What time do you go to bed? What time do you usually wake up?
How is your quality of sleep? Do you wake up feeling rested?
HYDRATION
How much water do you drink a day?
Do you drink coffee? How much?
Do you drink soda or juice? How much?
Do you drink alcohol? How much?
MOTION
How would you rate your energy level on a scale of 1-10 (10 being optimum energy)
How often do you exercise?
Are there things you can't do that you would like to do becasue of your health or energy level?
STRESS
How would you rate your stress level on a scale 1-10? 1 being no stress
What do you do for work and do you enjoy it?
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 in between? If so, what snacks do you prefer?
How many times a week do you eat out?
PHYSIQUE
Current Weight
Goal Weight
Height
On a scale of 1-10, (10 meaning ready to go) how motivated are you to start working on your health goals?
In the past, what has been the most difficult thing about losing/maintaining weight?
ENVIRONMENT
How healthy would you rate your surroundings? (1-10)
Do you have healthy and active friends, supportive family?
Is there anyone in your life who would like to get healthy with you?
Thank you for your honest and thoughtful answers regarding your current health and habits. Habit building is key to long term success. I appreciate you taking the time to complete this form and I would love to talk with you further to recommend the program that would be the best fit for you. Let's schedule a time! Message me upon completion of this form.

Thank you,

Mary Bodnar
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Mary Bodnar

Your Health Assessment