Vozzolo Health & Wellness Mini Health Assessment

HEALTH ASSESSMENT

Chelsea Vozzolo, MS, RDN, CHC
Name
Email
example@example.com
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's Date
City
State
Two Letter Abbreviation
Zip Code
Phone Number
Format: (000) 000-0000.
Current Age:
How did you hear about me?
If you were referred, name of person who referred you.
Preferred Method Of Contact
Awaken...Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)

0/330
Describe where you would like to be in your Health...

0/330
Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, upcoming special event, etc.)

0/330
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 health goal(s))?

0/330
MEDICAL
Do you have the following

Other
Are there any diagnosed food or other allergies that I should be aware of?

0/160
Are you taking any medications for:

Other
Are you taking other medications or have other medical conditions that could influence which program we choose?

0/185
*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.
MOTION
How would you rate your energy level? (on a scale of 1-10, 1=low, 10=high)
What physical activities do you enjoy?
EMPLOYMENT
Do you currently work?

Other
If so, briefly describe your occupation and type of work:
STRESS
How would you rate your stress level? (on a scale of 1-10, 1=low, 10=high)
What are the biggest sources of stress for you?
EATING HABITS
How would you describe your current eating pattern? Best examples would be what a normal day of eating & drinking looks like for you from the time you wake up until the time you go to bed.
WEIGHT

Note: weight is always kept private and necessary to determine which program would be the best fit based on your health goals.
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
What weight loss plans have you tried in the past? What has been most difficult about losing/maintaining weight in the past?

0/200
Is there anyone in your life who would like to get healthy with you?
Do you have a Health Savings Account (HSA)?
Is there any other information about your health that would be helpful to know? Please type additional questions or concerns here:
How did you hear about Vozzolo Health & Wellness?

Other
Should be Empty:

HEALTH ASSESSMENT

EMPLOYMENT