Your Health Journey Starts Here

1
Full Name* This field is required.
2
Email* This field is required.
example@example.com
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Date* This field is required.
Today's Date
Month
Day
Year
4
Address* This field is required.
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City* This field is required.
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State* This field is required.
Two Letter Abreviation
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Zip Code* This field is required.
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Phone Number* This field is required.
Area Code
Phone Number
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Date of Birth
Date
Month
Day
Year
10
Who referred you to our program?* This field is required.
If you were referred, name of person who referred you.
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Preferred Method Of Initial Contact
Text
Call
Email
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Awaken...Discover where you are and where you want to be!
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Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)* This field is required.
0/330
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Describe where you would like to be in your Health...* This field is required.
0/330
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Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)* This field is required.
0/330
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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)?* This field is required.
0/330
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Medical
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Are You Pregnant
Yes
No
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Are You Nursing
Yes
No
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If yes, how old is your baby
21
Do you have the following
Diabetes - Type 1
Diabetes - Type 2
High Blood Pressure
Gout
22
Are there any food or other allergies that I should be aware of?
0/160
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Are you taking any medications for:
Diabetes
High Blood Pressure
High Cholesterol
Thyroid**
Lithium*
Coumadin (Warfarin)***
24
Are you taking other medications or have other medical conditions that could influence which program we choose?* This field is required.
0/185
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*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.
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SLEEP
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How many hours of sleep do you typically get?
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What time do you typically go to bed?
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What time do you typically wake up?
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How is your quality of sleep?
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Do you wake up feeling rested?
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HYDRATION
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How much water do you drink each day?
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How much Coffee?
35
How much Soda?
36
How much Tea?
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How much Alcohol?
0/50
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MOTION
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How would you rate your energy level? (on a scale of 1-10)
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How many times a week do you exercise?
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What physical activities do you participate in?
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Are there things you can't do that you would like to be able to?
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STRESS
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How would you rate your stress level? (on a scale of 1-10)
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What do you do for work?
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How much do you enjoy what you do?
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Are there other stressors in your life?
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EATING HABITS
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How many meals per day do you eat?
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When do you eat your first meal?
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When do you eat your last meal?
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Do you snack between meals?
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What kind of snacks?
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How many times a week do you eat out?
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Where?
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WEIGHT
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Current Weight
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Goal Weight
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Height
60
Have you tried to lose weight before?
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What has been most difficult about losing/maintaining weight in the past?* This field is required.
0/200
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SURROUNDINGS
63
How healthy would you rate your surroundings? (on a scale of 1-10)
64
Do you have healthy & active friends, supportive family, keep junk food in the house, etc?
65
Is there anyone in your life who would like to get healthy with you?
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