HEALTH ASSESSMENT Chuck Rossi

HEALTH ASSESSMENT Chuck Rossi
First and Last Name*
Email*
example@example.com
Phone*
Address*

Street Address

Street Address Line 2

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STEP 1: AWAKEN
1. What would you like to accomplish with your health? This could be weight loss, improved sleep, better response to stress, etc.*
2. What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc.*
3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?*
4. Tell me about your health: Do you have any allergies or medical conditions that could influence which program we choose?*
5a. Are you pregnant?

YesNo
5b. Are you Nursing?

YesNo
6. Are you taking any medications for:

DiabetesHigh Blood PressureLithium*ThyroidCoumadin/WarfarinOther
Are you now using, or considering using, any medications for weight loss? (Semiglutide, GLP-1, etc.)

Yes
7. Do you have the following?

High Blood PressureDiabetes Type 1Diabetes Type 2GoutGluten Intolerance/SensitivitySoy Allergy or IntoleranceFood AllergiesOther
*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.
STEP 2: DAILY ROUTINES AND HABITS
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
How would you describe the quantity & quality of the activity you do each week?
How many hours a day do you sit?
How many days a week do you exercise (0-7 days)?
What types of physical activity do you enjoy?
Mind
On a scale of 1-10 how fulfilled are 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?
On a scale of 1-10 how much do you enjoy what you do?
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?
How many ounces of water do you drink per day?
Do you drink other beverages? Coffee, soda, alcohol, tea, etc.?
If so, how often and how much?
The average person spends $15-$25 per day on food and drink. How much do you think you spend?
Weight Management
Are you comfortable sharing your age?
How tall are you?
How much do you currently weigh?
What would you consider to be a healthy weight for you?
Have you tried to lose weight in the past?
What has been difficult for you about losing & maintaining weight?
Surroundings
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.)
Is there anyone in your life who would like to get healthy with you?
Is there anything else you think I should know about your health?
Should be Empty: