Tell me about you....

HEALTH ASSESSMENT
Name
Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ST
Zip
Phone
Email
example@example.com
How did you hear about working with me?
Preferred method Of Contact - I will be in touch very soon to chat about the perfect program for you.

CallEmailText
Describe where you are in your health now. ( Weight, sleep, stress, energy, etc)
Describe where you would like to be in your health.
What physical activities do you participate in?
How many times a week do you exercise?
Please describe WHY you are interested in getting healthy. (What is your main Motivation? Relationships, activities, how you will feel, etc) On a scale from 1-10 how motivated are you to take back your health?
Are there things you can't do that you would like to be able todo in the future?
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if thats part of your goal)?
What do you do for work?
Are you Nursing?

YesNoYesNo If yes, how old is your baby?
If yes, how old is your baby?
Are you taking other medications or do you have other medical conditions that could influence which program we choose:
Thyroid

High Blood PressureLithium
Are you taking any medications for

Diabetes Type 1DiabetesDiabetes Type 2High Blood Pressure
Are there any food or other allergies that I should be aware of

Coumadin (Warfarin) 3
Are there any food or other allergies that I should be aware of

High Cholesterol
Coumadin (Warfarin) 3

GoutThyroid
Are there any food or other allergies that I should be aware of?
Current Weight
Goal Weight
Height
Have you tried to lose weight before? What have you tried?
Is there anyone in your life who would like to get healthy with you?
Should be Empty:

HEALTH ASSESSMENT