Health Can Be Simple Health Evaluation
Name
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Phone
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Format: (000) 000-0000.
Email
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Preferred Method of Contact
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Address
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Street Address
City
State / Province
Postal / Zip Code
Referred From?
Health goals / motivation behind them? (Weight, muscle, energy, etc.)
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What have you tried in the past?
3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?
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4. Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?
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5a. Are you Pregnant?
No
Yes
5b. Are you Nursing?
No
Yes
6. Are you taking any medication for:
Diabetes
High Blood Pressure
Lithium*
Thyroid
Coumadin (Warfarin)
Other
7. Do you have any of the following:
High Blood Pressure
Diabetes - Type 1
Diabetes - Type 2
Gout
Gluten Allergy or Intolerance
Soy Allergy or Intolerance
Food Allergy (Medically Diagnosed)
Other
*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.
Tell me about your sleep:
What you drink daily / how much? (Water, Coffee, Soda, Alcohol, etc.)
Biggest struggles with food?
How often do you eat out?
Describe your exercise (Frequency, Intensity, Duration):
Rate your stress (scale of 1-10). Primary source of stress?
Current Height/Weight? What's a healthy weight for you?
Who would like to get healthy with you?
On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?
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On a scale of 1-10, how much do you enjoy what you do?
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How many meals and snacks do you eat per day?
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When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
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Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
Age
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Height
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How much do you currently weigh?
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What would you consider to be a healthy weight for you?
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Have you tried to lose weight in the past?
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What has been difficult for you about losing and maintaining weight?
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On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, keep junk food in the house, etc
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Is there anyone in your life who would like to get healthy with you?
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Is there anything else you think I should know about your health?
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Submit
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