Winn Health
Corey and Peter Winn: Partnering with you to reach your health and wellness goals!
Health Evaluation Form
The following questionnaire is a comprehensive look at your health. It will take about 5-10 minutes to complete.
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Prefer not to answer
E-mail
Phone Number
*
Format: (000) 000-0000.
Name used on Social Media
Name used on social media accounts
Who can I thank for referring you my way? Enter N/A if not applicable.
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Begin
GENERAL HEALTH INFORMATION
What would you like to accomplish in your health?
*
Lose weight
Gain weight
Build muscle
Improve sleep
Gain energy
Learn healthy habits
Reduce inflammation
Other
Do you have any of these health conditions?
Type 1 diabetes
Type 2 diabetes
High blood pressure
Low blood pressure
Hypothyroidism
Hyperthyroidism
Gout
Cancer
Anxiety
Depression
Other
Do you take any of the following?
Thyroid medication
Coumadin (Warfarin)
Lithium
Multivitamin
Probiotics
Diuretics
Medications for diabetes
Medications for high blood pressure
Weight loss medications
Other
Do you have any of the following allergies, sensitivities, or dietary considerations?
Gluten allergies/intolerance
Soy allergies/intolerance
Vegetarian
Lactose allergies/intolerance
Pescatarian
Kosher
Vegan
Other
Are you pregnant or nursing?
*
Please Select
Neither
Pregnant
Nursing
Pregnant & nursing
Trying to get pregnant
Not applicable
Do you have any other allergies or medical considerations that should be taken into account when customizing a plan for you?
Age
*
13-17
18-49
50-64
65+
Weight if known
Height if known
The following three questions: 1 - 10 (1=low / 10=high)
How do you rate your current level of energy?
*
1 - What energy?
2
3 - Below average
4
5 - About Average
6
7
8 - Above average
9
10 - I have non-stop energy!
How do you rate your average stress levels?
1 - I have no stress at all
2
3 - Below average stress
4
5 - About average
6
7
8 - Above average stress
9
10 - I am stressed all the time
How many hours of sleep do you get per night?
*
Do you have trouble getting to sleep?
Please Select
No
Yes
Occasionally
Do you toss and turn or awaken easily?
Please Select
Yes
No
Do you snore or have breathing problems during sleep?
Please Select
Yes
No
Not sure
Any other health information you would like to share:
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Next
DIET & LIFESTYLE
Do you exercise?
*
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
How long do you usually exercise?
*
10-20 minutes
21-35 minutes
36-50 minutes
51+ minutes
Not applicable
Please list the types of exercise:
How many ounces of water do you drink in a day?
*
What do you drink other than water?
Coffee
Tea
Soda
Beer
Wine
Alcohol
Other
How much do you spend on all beverages in a month?
How often do you eat out? (Including breakfast, lunch, dinner, snacks, and coffee)
Never
Less than once per week
1-2 times per week
3-5 times per week
6-10 times per week
What types of food do you enjoy when eating out?
How much do you spend eating out per month?
Average is $10-$15 per meal eaten out.
About how much do you spend per month on groceries for yourself?
*
According to statistics from the US Department of Agriculture, the average American spends $438 per month on groceries.
On a scale of 1-10, how happy are you with your current health?
Please Select
1 - not happy
2
3
4
5
6
7
8
9
10 - extremely happy
On a scale of 1-10, how much do you worry about your health?
Please Select
1 - all the time
2
3
4
5
6
7
8
9
10 - never
What areas of your life cause the most stress?
What do you do for a living?
On average, do you consider your lifestyle sedentary, moderate, or active?
Please Select
Sedentary
Moderate
Active
Back
Next
GOAL SETTING
If you could lose any amount of weight without fail, how much would you choose to lose?
5-10
11-25
26-50
51-75
76-100
100+
I'm not looking to lose weight
I want to gain weight
Think about the last time you were happy with your health. What has happened between then and now?
If you achieved your health goals, what would be different in your life?
What is your main motivation for wanting to make a change in your health?
As you prepare to achieve your health goals, do you have any friends or family who are looking to improve their health?
Please feel free to forward them this assessment. Following a program with a friend or family member can add extra support and accountability to help all of you succeed.
This program contains 4 components to help to achieve your goals, build new habits, and ensure lasting, long-term success. Which component are you most excited about?
Health coaching for support and accountability
Community support so I know I'm not alone
Educational resources to help me understand proper nutrition, my relationship with food, and to build lasting success
Rock solid nutrition to help me meet my goals and feel fantastic in the process
Studies show that people who mentor others are 5x more likely to achieve and maintain their own goals. As you begin to transform your health, many people will turn to you as a guide to help them achieve their goals. Would you be open to exploring what it would look like to help your friends and family on their health journey?
Please Select
Yes
Maybe
No
I'd need more information
On a scale of 1-10, how ready are you to start working towards your goals?
Please Select
1 - I'm not ready
2
3
4
5
6
7
8
9
10 - I need this right now!
Is there anything else I should know to help me understand your needs and goals?
What 3 people would you love to see get healthy alongside you?
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