HEALTH ASSESSMENT FORM

WELCOME

Congratulations on taking the first step on this journey to achieving optimum health and overall well-being.
PERSONAL HEALTH ASSESSMENT QUESTIONNAIRE
Date*

MonthDayYear
Date
Weight LossEnergy, Performance & StrengthAnti-Aging, Sleep & Restorative HealthDigestive Health & Immune System SupportNutrition & CleansingAccountability & MindsetBrain Health & Body Balance
I feel tired and slow all the timeI feel foggy and confused at timesI feel periods of clarity with moments of mental exhaustionI feel clear but desire to support brain health
I have low energyI have energy if I keep going, but crash when I stopMy energy level is good, but could be betterI have energy all the timeI have good energy and want to maintain it as I age
I want to lose 5-20 poundsI want to lose 21-50 poundsI want to lose 50-100 poundsI want to lose over 100 poundsI need to gain weightMy weight is good, but I want to maintain it
NeverOnceMultiple Times
I eat healthyI try to eat healthy, but binge on sweets/junk foodHealthy, but not getting adequate protein and nutrients
YesNo
I look and feel older than my ageI look and feel my ageI look and feel younger than my age
DailyWeeklyMonthlyOccasionallyNever
YesNo
YesNo
YesNo
I exercise 5 or more times a weekI exercise 3 or more times a weekI try to exercise, but have no consistencyI do not exercise, but need to
HighModerateLowCalm & Balanced
NeverSometimesAlways
Very ImportantSomewhat ImportantNot That Important
HOW CAN WE GET IN TOUCH WITH YOU?
Name

First NameLast Name
WHAT IS YOUR PREFERRED METHOD OF CONTACT?
Phone Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Thank you!
Should be Empty:

WELCOME

PERSONAL HEALTH ASSESSMENT QUESTIONNAIRE