Health Survey- Christie Henry
Full Name
*
First Name
Last Name
E-mail
example@example.com
Best number to reach you on
Age
Note: Medical Conditions are private and HIPPA regulations are protected. Do you agree and give consent to discuss your medical history and medications. Type "Yes" if you agree. Any and all medical questions and medications will be discussed on a personal phone call.
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Are you currently taking any medications?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
Are you allergic to any types of foods? (Nuts, Milk, Soy...etc.)
Sleep
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
Please Select
Sedentary
On your feet
Active
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
This is
your name
. I shared this form with form with
my friends name
.
Would you like to hear more about how you could earn a supplemental income by helping others? Or replacing an income to start your own home based business? I would be honored to just explore it with you.
Submit
THANK YOU!!!
I will reach out to you shortly. You may also email me at info@zionrisksolutions.com
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