HEALTH ASSESSMENT
Lori Redding, Independent Certified OPTAVIA Coach - 336.337.0301
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
How did you hear about our program?
If you were referred, name of person who referred you.
Preferred Method Of Contact
Text
Call
Email
Awaken
...Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)
*
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Describe where you would like to be in your Health...
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0/330
Please describe WHY you are interested in getting healthy. (What is your main MOTIVATION... How would it impact you mentally, emotionally, and/or physically? What activities would you do more of? How would it impact your most important relationships?)
*
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 goal)?
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0/330
Medical
Are You Pregnant?
Yes
No
Are You Nursing?
Yes
No
If yes, how old is your baby?
Do you have the following?
Diabetes - Type 1
Diabetes - Type 2
High Blood Pressure
Gout
Are there any food or other allergies that I should be aware of?
0/160
Are you taking any medications for:
Diabetes
High Blood Pressure
High Cholesterol
Thyroid**
Lithium*
Coumadin (Warfarin)***
Do you have kidney disease, or any other specific protein limitations?
*
0/185
Are you taking other medications or have other medical conditions that could influence which program we choose?
*
0/185
SLEEP
How many hours of sleep do you typically get?
What time do you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much Coffee?
How much Soda?
How much Tea?
How much Alcohol?
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MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
STRESS
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
EATING HABITS
How many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Where?
WEIGHT
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
*
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SURROUNDINGS
Who will support you in this journey?
Who might be a stumbling block to your progress?
Is there anyone in your life who would like to get healthy with you?
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