Lifestyle Assessment Form

Lifestyle Assessment Form

Please complete this form to provide us with important information about your habit history and current lifestyle status. This information will help us provide you with the best possible care.
I agree to the terms and conditions outlined in the privacy policy regarding the collection and use of my Lifestyle information for this assessment.*
I consent to receiving communications related to my Lifestyle assessment and potential follow-up care.*
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How would you rate your overall health?*

ExcellentGoodFairPoor
Do you have any of the following medical conditions?*

DiabetesHeart DiseaseHigh Blood PressureAsthmaArthritisNoneOther
Are you currently taking any medications?*

YesNo
If yes, please list the medications and dosages:
What is your biggest challenge right now that you would like to change?
What has been a recent celebration/success within this challenge?
What is your biggest fear if this challenge remains as it is for the next 3 to 5 years or longer?
What are your current habits or routines around this issue? Please be as specific as possible.
What change would you like to see in 30 days from now? how about 90 days from now? How would you feel when you got this result?
What are specific results you expect from our time together?
What are are 5 things you Love about your Life right now?
Current Energy and Lifestyle check-in : Rate below from 1 ( poor ) to 10 (excellent) : A: Physical Energy B: Emotional Balance C: Stress Management D: Nutrition&Eating Habits E: Sleep&Recovery
Relationships and Support : Rate below from 1 ( poor ) to 10 (excellent) : A: Time for yourself B: Joy & Fulfillment C: Connecting to what is most important to you.
How often do you exercise?*

DailyA few times a weekOccasionallyRarelyNever
Do you smoke?*

YesNo
Do you drink alcohol?*

YesNo
If yes, how many alcoholic beverages do you consume per week?
Please list anything else you would like to share:
Should be Empty: