Health Assessment Client Form

Health Assessment Form

Health Coaching with Emily & Andrew Fleming
First Name*
Last Name*
Age*
Gender*
Phone Number*
Confirm Phone Number*
Please enter a valid phone number.
E-mail Address*
example@example.com
Confirm Email Address*
example@example.com
Instagram Handle*
Today's Date*
How did you hear about our Health program?*
If a friend referred you, please type their full name.
Preferred method of contacting

TextPhone callEmail
Questions and Details:
Tell me more about yourself. What would you like to change in your health?
Please describe your WHY, and be as detailed as possible. Why are you interested in making changes in your health? (What is your main motivation...relationships, activities, how you feel, etc. How will your life improve when you start chasing health?)
When was the last time you remember feeling your best in your health or being at your ideal weight or size? (If that is part of your goal).
Medical Questions
Are you pregnant?

YesNo
Are you nursing?

YesNo
Do you have any of the following

Type 1 DiabetesType 2 DiabetesHigh Blood PressureGoutThyroid IssuesNone of the Above
Are you taking any medications

For DiabetesFor High Blood PressureFor ThyroidLithiumCoumadin (Warfarin)No medications
Any food allergies that I should be aware of? (soy, lactose, gluten, etc)
Are you taking other medications or have other medical conditions that could influence which program we recommend for you?
*Lithium: 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 level while the client is on program and adjust medication.

***Coumadin (Warfarin): The healthcare provider may wish to review food choice, conduct lab work and/or adjust medication.
If weight loss is not your goal, how else can I help you?
Should be Empty:

Health Assessment Form

Questions and Details: