Health Assessment
I am EXCITED to partner with you on your Health Journey! Get Healthy With Coach Amy!
Today's Date
*
 /
Month
 /
Day
Year
Name
*
Email
*
example@example.com
Phone
*
Social Media Profile Name
Who referred you?
If you were referred, please put the name of the person who referred you OR where you saw this link.
Let's Discover Where You Are & Where You Want to Be!
What you would like to accomplish with your health?
Are you taking any of the following medications or have any of the following allergies? If medication/allergy/medical condition is not listed, please list in the other option.
High Blood Pressure
Diabetes
Diabetes Type I
High Blood Pressure
Diabetes Type II
Gout
Thyroid
Gluten Intolerance or Allergy
Lithium
Coumadin (Warfarin)
Soy Allergy
Food Allergies
Other
Are you Pregnant?
Yes
No
Are you Nursing?
Yes
No
If yes, how old is your baby?
Do you have any allergies or medical conditions not discussed above that could influence the system we design for you?
Do you have any food aversions - tastes, textures, etc - that you cannot take? Please list below.
List below the situations or factors that are making your life so difficult that you cannot prioritize your health.
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
Can you tell me about a time in your life when you were healthier? What has changed between then and now?
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
MOTION
Are there things you can't do that you would like to do?
How many days a week do you exercise? (0-7 days)
Describe your workouts. Include length of workouts and types of workouts, i.e. cardio, weightlifting, etc.
What types of physical activity do you enjoy in general? Think movement over exercise.
MIND
On a scale of 1-10, how fulfilled are you with where you are in your health & life currently?
On a scale of 1-10, how much do you worry about your health, family, life in general currently?
What area of your life tends to be the biggest stress for you?
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?
What do you believe is keeping you from losing weight? Gaining weight? Increasing energy? Reaching whatever the goal is that you set for yourself?
Would you say you are more outgoing or reserved?
Please Select
Outgoing
Reserved
Would you say you are more task oriented or more people oriented?
Please Select
Task Oriented
People Oriented
FOOD & HYDRATION
How many meals and snacks do you eat per day?
When do you eat your first meal of the day?
How many times a week do you eat out? And where? Include beverages, snacks, etc.
The average American spends approx. $15-$20 a day/per person on groceries, beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average?
*
$10
$15
$20
$25+
Do you enjoy drinking water?
Do you drink other beverages, such as:
How many ounces of water daily?
How many cups of coffee? How do you take it?
How much soda/ice tea/energy drinks/other non-alcoholic beverages daily?
How much alcohol weekly or monthly do you consume? What are your drinks of choice?
Do you prefer sweet foods, savory foods, or a blend of the two?
Please Select
Sweet
Savory
Blend
WEIGHT MANAGEMENT
What is your current age?
How tall are you?
How much do you currently weigh?
How much do you want to weigh?
Have you tried to reach these health goals in the past? If so, what have you tried?
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (Consider things like - do you have healthy and active friends, supportive family, a lot of junk food in the house, etc.)
Is there anyone in your life who you would like to get healthy with you?
Is there anything else you think we should know about your health?
Take a moment to scroll through these images and then answer the question below the gallery.
You may need to turn phone sideways to see full pictures.
After seeing what's possible, rate on a scale of 1-10 how ready are you to make the changes necessary to make your goals become your reality.
Submit
Should be Empty: