Cynergy Nutrition Health Assessment

Cynergy Nutrition Health Assessment
Client Information
Name
Date

MonthDayYear
Date
Date of birth

MonthDayYear
Date
Which Program are you registering for:
Gender
Height
Current weight
Email
example@example.com
Mobile phone
Please enter a valid phone number.Format: (000) 000-0000.
Home phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred contact method

Other
Preferred contact method - Other (please specify)
Emergency contact name
Emergency contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Goals and Desired Changes
In general, what are your goals?

Other
In general, what are your goals? - Other (please specify)
How, specifically, would you like your habits, your health, your eating, and/or your body to be different?
Most important / urgent change 1
Most important / urgent change 2
Past Attempts and Barriers
Have you tried anything in the past or recently to change your habits, your health, your eating, and/or your body?

Other
Which of those things worked well for you, and why?
Which of those things didn’t work well for you, and why not?
If you were to consider maybe making more changes to your habits, your health, your eating, and/or your body, what might those be?
Until now, what has blocked you or held you back from changing these things?
Nutrition, Activity, and Household Context
Right now, how would you rank your overall eating/nutrition habits?

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Why? (nutrition rating)
Are you regularly active in sports and/or exercise?
Hours per week of sports/exercise
What types of sports and/or exercise do you typically do?
Hours per week of other physical activity
What other types of movement and/or activities do you do?
Who lives with you?

Other
Do you have children?
If yes, how many and what are their ages?
Who does most of the grocery shopping in your household?

Other
Who does most of the cooking in your household?

Other
Who decides on most of the menus/meal types in your household?

Other
Health History and Current Health
Have you been diagnosed with any significant medical conditions and/or injuries?

Other
Right now, do you have any specific health concerns, such as illnesses, pain, and/or injuries?

Other
Right now, are you taking any medications, either over-the-counter or prescription?

Other
On a scale of 1–10, how would you rank your health right now?
Why? (health rating)
Lifestyle, Stress, and Time Use
Hours per week spent on work or job-related duties
Hours per week spent on commuting or travel
Hours per week spent on household chores or errands
Hours per week spent caring for children or dependents
Hours per week spent on exercise or physical activity
Hours per week spent on hobbies or leisure activities
Hours per week spent on screen time or social media
How do you feel about your schedule, time use, and overall busyness?
Typical stress level on an average day
Average hours of sleep per night
How do you normally cope with your stress?
Readiness, Expectations, and Signature
How READY are you to change your behaviors and habits?

1

2

3

4

5

6

7

8

9

10

1 is Not ready, 10 is Fully ready
How WILLING are you to change your behaviors and habits?

1

2

3

4

5

6

7

8

9

10

1 is Not willing, 10 is Fully willing
How ABLE are you to change your behaviors and habits?

1

2

3

4

5

6

7

8

9

10

1 is Not able, 10 is Fully able
What do you expect from me as your coach?
What are you prepared to do to work towards your goals?
Client signature
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Cynergy Nutrition Health Assessment

Client Information

Goals and Desired Changes

Past Attempts and Barriers

Nutrition, Activity, and Household Context

Health History and Current Health

Lifestyle, Stress, and Time Use

Readiness, Expectations, and Signature