Health Assessment
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Who referred you to our program?
*
If you were referred, name of person
Preferred Method of Contact to Set Up Call with Me?
*
Text
Call
Email
AWAKEN
Discover where you are and where you want to be!
Describe where you are in your health right now... (Weight, sleep, stress, energy, etc.)
*
Describe where you would like to be in your health, what would life look like, what would you be doing that you don't do right now?
*
Please describe WHY you are interested in getting healthy. What is your main motivation?
*
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?
*
Medical Questions
Are you pregnant?
*
Yes
No
Are you nursing?
*
Yes
No
If yes, how old is your baby?
Do you have any of the following?
*
Diabetes Type 1
Diabetes Type 2
Gout
High blood pressure
PCOS
None
Other
Are there any food or other allergies that I should be aware of?
*
Are you taking any medications for any of the following?
*
Diabetes Type 2 stable blood sugar
Diabetes Type 2 UNstable blood sugar
Diabetes Type 1
High blood pressure
High cholesterol
Thyroid**
Coumadin (Warfarin)***
NONE
Other
Are you taking other medications or have other medical conditions that could influence which program we choose?
*
*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.
Sleep Habits
How many hours of sleep do you typically get per night?
*
What time do you typically wake up?
*
How is your quality of sleep and do you feel rested?
*
Hydration
How many ounces of water do you drink per day?
*
How much coffee?
*
How much soda?
*
How much tea?
*
How much 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 activities do you participate in? (i.e. around the house, at work, etc.)
*
How would you describe your daily activity level? Sedentary or Extremely active or somewhere in between?
*
Stress
How would you rate your stress level on a scale of 1-10, 10 being extremely stressful?
*
What do you do for work?
*
What are your other stressors in your life?
*
Eating Habits
How many meals per day do you eat?
*
When do you eat your first meal?
*
When do you eat your last?
*
Do you snack in between meals ?
*
What kind of snacks?
*
How many times a week do you grab food on the go? (gas station, coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
*
Weight
Current Weight
*
In a perfect world, if you could not fail, how many pounds do you want to lose?
*
How tall are you?
*
What has been the most difficult thing about losing/maintaining weight in the past?
*
How healthy would you rate your surroundings, do you keep snacks, sodas, temptations around? (on a scale of one to 10, 10 being healthiest) ?
*
Do you have healthy and active friends, a supportive family, do you keep a junk food in the house, etc.?
*
Is there anyone in your life who would like to get healthy with you?
*
Submit
Should be Empty: