Health Assessment Form

Coach Deby’s Path to Health Profile Form

Let’s find the right plan for you!
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What would you like to accomplish with your health? (select all that apply)*

Weight LossWeight GainBuild MuscleImproved SleepGain EnergyBetter Response to StressReduce InflammationOther
Are you pregnant?*

YesNo
Are you nursing?*

YesNo
Do you have any allergies or medical conditions that could influence the plan we customize for you?
What are your taste preferences?

ChocolateVanillaStrawberryPeanut butterLemonChocolate MintCinnamonSoupsPastasChocolate chip cookiesBrowniePuddingBBQCaramelOatmealPancakesMashed PotatoesCoffee flavorsOther
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc*
How many hours of sleep do you get in a typical night?*
How many meals and snacks do you eat per day?*
How many times a week do you eat out? And where? Include beverages, snacks, etc.*
The average American spends approx. $15-$20 a day/person on groceries, beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average?*

$10$15$20$25+
How many ounces of water do you drink per day?*
Do you drink other beverages, such as:*

CoffeeSodaTeaWineAlcohol
How many cups of coffee? Do you add anything to it? (creamer, etc)*
How much soda/ice tea/energy drinks/other non-alcoholic beverages daily?*
How much alcohol weekly or monthly do you consume? What are your drinks of choice?*
What is your current age?*
Are you at your ideal weight? If not, how much weight would you like to lose or gain?*
Have you tried to reach these health goals in the past? If so, what have you tried?
Additional comments you want me to know:
Should be Empty:

Coach Deby’s Path to Health Profile Form