Build For Life Health Assessment

HEALTH ASSESSMENT
PERSONAL INFORMATION
Name*

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
How did you hear about my program?
BODY MEASUREMENTS
Height*
Current Weight*
Goal Weight*
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
DISCOVER WHERE YOU ARE AND WHERE YOU WANT TO BE!
If you had to describe your current state of health, what would you say and why?*
Describe where you would like to be in your health.*
Please describe why you are interested in getting healthy and what is your motivation (feeling better, kids, ,grand children, spouse, family illnesses)*
How many years ago did you feel you were in your best health or being at your ideal weight or size?*
MEDICAL INFORMATION
Are you pregnant?*
Are you nursing?*
Do you have any of the following:*

Diabetes - Type 1Diabetes - Type 2High Blood PressureGoutNone of the above
Are you taking any medications for:*

DiabetesThyroid**High Blood PressureLithium*High CholesterolCoumadin (Warfarin)***None of the above
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
Are you taking any medications (including GLP-1 or other peptides) or have any medical conditions that affect your diet?*
Are you taking any supplements regularly if so what kind?*
Are you taking any vitamins if so what?*
When was the last time you had a blood test?*
Do you have a copy or can you get a copy of your last blood test?*

YesNoN/A
Have you had any body composition tests like an InBody, Dexa Scan, etc. if so what type?*
Do you have a copy of your last body composition test?*

YesNoN/A
SLEEP
How many hours of sleep do you typically get?*
What time do you typically go to bed?*

Hour Minutes

AM/PM Option
What time do you typically wake up?*

Hour Minutes

AM/PM Option
How would you rate your sleep.

1

2

3

4

5

1 is Worst, 5 is Best
Do you wake up feeling rested?

YesNoSometimes
HYDRATION
How many glasses of water do you drink a day?
How many cups of coffee do you drink a day?
How many cans of soda do you drink a day?*
How many cups/glasses of tea do you drink a day?
How many alcoholic drinks do you drink a week?*
How many days of the week do you drink alcoholic beverages?*
EXERCISE
How would you rate your energy level.

1

2

3

4

5

1 is Bad, 5 is Great
How many days a week do you exercise.

0

1

2

3

4

5

6

7

0 is , 7 is
What type of physical activities do you do?

WalkingRunningStrength TraingOther
Are there things that limit you from exercise?
Are there things you can't do that you would like to be able to do?
STRESS
How would you rate your stress level.

1

2

3

4

5

1 is Minor, 5 is Extreme
What do you do for work?
How much do you enjoy your career?

1

2

3

4

5

1 is Not at all, 5 is Love it!
Are there specific stressors in your life?
EATING HABITS
How many meals per day do you eat?

1

2

3

4

5

6

7

1 is , 7 is
What time do you eat your first meal?

Hour Minutes

AM/PM Option
What time do you eat your last meal?

Hour Minutes

AM/PM Option
Do you snack between meals?*

YesNo
What kind of snacks?
How many times a week do you eat out?
Where do you typically eat out?
SURROUNDINGS
Do you have healthy & active friends?

YesNoSome
Is your family supportive?

YesNoSomewhat
How healthy would you rate your surroundings?

1

2

3

4

5

1 is Not At All, 5 is Very Healthy
Is there anything else you feel you should or would like to share with me?
Is there anyone in your life who would like to get healthy with you? If so who (name & relationship)?
Should be Empty:

HEALTH ASSESSMENT

PERSONAL INFORMATION

BODY MEASUREMENTS

DISCOVER WHERE YOU ARE AND WHERE YOU WANT TO BE!

MEDICAL INFORMATION

SLEEP

HYDRATION

EXERCISE

STRESS

EATING HABITS

SURROUNDINGS