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
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who referred you?
*
What are you main goals in your health? What prompted you to want to know more?
*
If you woke up tomorrow and you were at your ideal weight or health, what would be different from today?
*
Tell me about a time that you felt healthy.
What do you do for work? Please mention how active your job is.
One to five, how stressful is your job?
No stress
1
2
3
4
Very stressful!
5
1 is No stress, 5 is Very stressful!
Do you follow a regular workout schedule? If so, how often and at what intensity? Please describe.
Tell me about your sleep
Night owl
Early bird
Restless sleep
Sleep like a rock
Other
Walk me through your typical day of eating. Please include what you’re drinking too.
How often do you eat outside of the home? Drive thru, carry out, coffee stops, gas station snacks, vending machine...
How ready are you to make a change in your health?
Not so much
1
2
3
4
Ready! NOW IS MY TIME!
5
1 is Not so much, 5 is Ready! NOW IS MY TIME!
I am looking forward to connecting with you soon about your health goals! In the mean time, I will add you to our private FB group with more information.
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