Health Survey
Please fill out this health survey
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contacts
Phone Call
Email
Phone Message
Other
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Age
Ex:23
Gender
Please Select
Male
Female
N/A
Medical
Do you have any of the following?
High blood pressure
Diabetes - Type 1
Diabetes - Type 2
Gout
Are you taking any medications for
Diabetes
Thyroid
High blood pressure
Lithium
High cholesterol
Coumadin (Warfarin)
Are you pregnant?
Yes
No
N/A
Are you nursing?
Yes
No
Do you have any food allergies?
Yes
No
Please describe
BMI
Height
Height in inches
Weight
Weight in lbs
What is your current BMI number?
What is the BMI value for the weight you want to maintain at?
Sleep
In general, at what time do you go to bed?
In general, when do you wake up?
On average, how many hours of sleep do you get?
Do you wake up feeling rested?
Yes
No
Other
How is the quality of your sleep?
Hydration
In a day, how much water do you drink usually?
In a day, how much coffee do you drink usually?
In a week, how much alcohol do you consume usually?
Movement
How many times per week do you exercise?
What kind of exercise do you participate in?
Are there things you would like to do that you are currently unable to?
How would you rate your daily energy level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Stress
What do you do for work?
Do you enjoy what you do?
Are there any other stress in your life?
Rate your overall stress level
Lowest
1
2
3
4
Highest
5
1 is Lowest, 5 is Highest
Eating Habits
When do you eat your first meal?
When do you eat your last meal?
How many meals per day do you eat?
Do you snack? If yes, what do you snack on?
How often do you eat out in a week?
Always
Usually
Sometimes
Rarely
Never
Other
Where do you typically eat out?
Weight
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
Yes
No
What have you found to be the most difficult part of losing weight in the past?
Do you smoke?
1 Pack/day
2 Packs/day
+3 Packs/day
No
Do you do any exercise?
1 - 3 a week
3 - 5 a week
Everyday
Never
How many hours do you sleep?
Less than 5 hours
5 - 6 hours
7 - 8 hours
9 - 10 hours
More than 10 hours
Thank You! We will contact you shortly.
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