HEALTH EVALUATION

Health Evaluation

Nancy Gonzalez CoachNancyG03@gmail.com
Thank you for submitting this Health Evaluation.

I will reach out to you shortly!
Name*
Phone*
Email*
Preferred Method of Contact*
Referred From?
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*
4. Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?*
STEP 2: DAILY ROUTINE & 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 days a week do you exercise? (0 - 7 days)*
What types of physical activity do you enjoy?
MIND
What area of your life tends to be the biggest stress for you?
FOOD & HYDRATION
How many ounces of water do you drink per day?*
Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
WEIGHT MANAGEMENT
Age*
Have you tried to lose weight in the past?*
What has been difficult for you about losing and 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:

Health Evaluation

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS