Free Health Assessment

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Name * This field is required.
First
Last
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Phone Number* This field is required.Mobile Number Preferably
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Email* This field is required.
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Address* This field is required.Where you get physical packages sent
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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How do you learn best?* This field is required.
Digital / Audio
Book / Reading
Both
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Who referred you? How did we come in contact?
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Where are you in your health right now?* This field is required.
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Where would you like to be in your health?* This field is required.Weight loss, improved sleep, more energy? What are your biggest stressors?
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Why are you interested in getting healthy now?* This field is required.What's your motivation? Feel better, better relationships, desire for activities, etc.
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Can you tell me about a time in your life when you were healthier?* This field is required.What has changed since then?
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Date of Birth* This field is required.
Month
Day
Year
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Height* This field is required.
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Current Weight (lbs)* This field is required.
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Goal Weight (lbs)* This field is required.
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Have you tried to lose weight before?* This field is required.What was most difficult about losing or maintaining your weight in the past?
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Are you taking any medications for the following?* This field is required.If Other, type in your medication
Diabetes
High Blood Pressure
High Cholesterol
Thyroid
Depression
Bipolar
N/A
Other
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Do you have any of the following medical conditions?* This field is required.Check all that apply
Diabetes Type 1
High Blood Pressure
Diabetes Type 2
Gout
Gluten Intolerance or Sensitivity
Soy Allergy or Intolerance
Food Allergies
N/A
Other
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Are you pregnant?* This field is required.
YESNO
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Are you nursing?* This field is required.
YESNO
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How many hours of sleep do you typically get per night?* This field is required.
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What time do you typically Go to Bed and Wake Up?* This field is required.
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Please rate the following* This field is required.5 being the best/most
5
4
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2
1
Quality of sleep
Row 0, Column 0
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Wake up rested
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Energy level in day
Row 2, Column 0
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Quality of sleep
Wake up rested
Energy level in day
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Row 0, Column 0
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What physical activities do you participate in TODAY?* This field is required.Working out, sports, running, walking, etc.
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Are there activities or other things you would like to do in the FUTURE that maybe you can't do today?* This field is required.
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With regards to activity, how would you rate your level of the following?* This field is required.5 being the most
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Workout frequency
Row 0, Column 0
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Workout intensity
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Energy
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Endurance
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Workout frequency
Workout intensity
Energy
Endurance
5
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What do you do for work?* This field is required.
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How would you rate the following?* This field is required.5 being the most
5
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Work enjoyment
Row 0, Column 0
Row 0, Column 1
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Row 0, Column 4
Work stress
Row 1, Column 0
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Home enjoyment
Row 2, Column 0
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Home stress
Row 3, Column 0
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Amount you worry
Row 4, Column 0
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Life fulfillment
Row 5, Column 0
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Your surroundings
Row 6, Column 0
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Row 6, Column 3
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Work enjoyment
Work stress
Home enjoyment
Home stress
Amount you worry
Life fulfillment
Your surroundings
5
Row 0, Column 0
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Row 0, Column 1
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Row 0, Column 3
1
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Row 1, Column 0
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On a scale of 1-5 (5 being most), how fulfilled are you with your life & why?* This field is required.Explain why you rated yourself that score
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Do you have healthy/active friends? Supportive family members?* This field is required.
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Is there anyone else you can think that would like to get healthy with you?* This field is required.
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What time do you eat your FIRST MEAL & your LAST MEAL?* This field is required.
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How many MEALS & SNACKS do you eat a day & what do they look like?* This field is required.
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How many times a week do you EAT OUT & what does it look like?* This field is required.
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How much of the following do you drink on an AVERAGE DAY?* This field is required.Look to the serving amounts in parenthesis
Lots +6
Moderate 3-5
Little 1-2
None
Water (bottles)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Coffee/Tea (cups)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Soda (cans)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Beer (bottles)
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Wine (glasses)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Liquor (cocktails)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Water (bottles)
Coffee/Tea (cups)
Soda (cans)
Beer (bottles)
Wine (glasses)
Liquor (cocktails)
Lots +6
Row 0, Column 0
Moderate 3-5
Row 0, Column 1
Little 1-2
Row 0, Column 2
None
Row 0, Column 3
Lots +6
Row 1, Column 0
Moderate 3-5
Row 1, Column 1
Little 1-2
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None
Row 1, Column 3
Lots +6
Row 2, Column 0
Moderate 3-5
Row 2, Column 1
Little 1-2
Row 2, Column 2
None
Row 2, Column 3
Lots +6
Row 3, Column 0
Moderate 3-5
Row 3, Column 1
Little 1-2
Row 3, Column 2
None
Row 3, Column 3
Lots +6
Row 4, Column 0
Moderate 3-5
Row 4, Column 1
Little 1-2
Row 4, Column 2
None
Row 4, Column 3
Lots +6
Row 5, Column 0
Moderate 3-5
Row 5, Column 1
Little 1-2
Row 5, Column 2
None
Row 5, Column 3
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Tags
Todo
In Progress
Done
Should be Empty: