Health Survey
Aishah Hunter - Healthy U
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies / Sensitivities
Do you have any food allergies? If yes, please describe :
Sleep
What time do you usually wake up?
What time do you usually go to bed?
Do you sleep well?
Please Select
Yes
No
Sometimes
Hydration
How much PLAIN water do you drink in a day?
*
How much coffee do you drink in a day? What do you put in it?
How much alcohol do you drink in a week?
Movement
How many times a week do you exercise?
What kind of exercise do you participate in?
Are there things you would like to do, that you currently are not physically able to?
How would you rate your daily energy level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Stress
What do you do for work?
Are there other stressors in your life?
How would you rate your stress level?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Eating Habits
When do you eat your last meal?
How many meals per day do you eat?
Do you snack? If yes, on what?
How often do you eat out in a week?
Weight
What is your primary health goal?
Weight Loss
Feel Better
Learn Healthy Habits
Other
If weight loss is your goal, how much weight would you like to lose?:
What is your height?
Have you tried to lose weight before? If so, what program/method did you use?
Submit
Should be Empty: