Your Wellness Assessment - First Steps
KAM Health Group
Today's Date
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Email
*
example@example.com
Best number to reach you at
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred method of initial contact?
Text
Call
Email
Name of person who referred you.
Areas if Interest and Current Level of Motivation
Discover where you are and where you want to be!
Describe where you are in your health now... (Weight, Sleep, Energy, etc)
*
Describe where you would like to be in your health...
*
Please describe WHY you are interested in getting healthy. (What is your main motivation... relationships, activities, how you feel, etc).
*
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)?
*
Background
Are you pregnant?
No
Yes
Are you nursing?
No
Yes
If yes, how old is your baby?
Do you have the following:
Diabetes- Type 1
Diabetes- Type 2
High Blood Pressure
Gout
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.
Are you taking any medications for"
Diabetes
High Blood Pressure
High Cholesterol
Thyroid*
Lithium**
Coumadin (Warfarin)***
Are you taking other medications or have other medical conditions that could influence which program we choose?
*
*Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the client is on the Program and adjust medication. Lithium** The healthcare provider may wish to adjust frequency of lab work for the clients and monitor. Coumadin (Warfarin)***: The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
Sleep
How many hours of sleep do you typically get?
What time fo you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
Hydration
How much water do you drink each day?
How much coffee?
How much soda?
How much tea?
How much energy drinks?
How much alcohol?
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
How many times a week do you exercise?
What physical/ exercise activities do you participate in?
Are there things you can't do that you would like to be able to?
Please Select
Sedentary
On your feet
Active
Stress
How would you rate your stress level on a scale of 1 (lowest) -10 (highest)?
What do you do for work?
How much do you enjoy what you do?
Are there any 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 meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
When you do eat out, is it usually fast food or sit-down?
Weight
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
*
Surroundings
How healthy would you rate your surroundings? (on scale of 1-10)
Do you have healthy & active friends, supportive family, keep junk food in the house, etc?
Is there anyone in your life who would like to get healthy with you?
Submit
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