Health Survey Form- Janice Brisbois 413-348-8373
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
Age
How did you hear about our programs?
Please describe your WHY to becoming a healthier version of yourself. (What is your main motivation? Relationships, activities, how you feel, etc)
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?
Please Select
Yes
No
Unsure
Are you nursing?
Please Select
Yes
No
If yes, how old is your baby?
Do you have any of the following?
Diabetes- Type 1
Diabeters- Type 2
High Blood Pressure
Gout
Kidney Disease
PCOS
Do you have any food allergies or dietary restrictions?
Please list any and all medications or supplements you are taking, and what you may be specifically taking them for
Are you taking any medications for:
Diabetes
High Blood Pressure
High Cholesterol
Thyroid
Blood Thinners
Other
Sleep
How many hours of sleep do you typically get per night?
What time do you typically wake up?
How is your quality of sleep? Do you rise feeling rested?
Hydration
How much water do you typically drink per day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical activities do you participate in?
How would you describe your daily activity level?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you wish to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who is empowered to get healthy with you?
Submit
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