HEALTH ASSESSMENT WITH SHELIE CARLSON

Name

Email

example@example.com

Date

Today's Date

Address

City

State

Two Letter Abreviation

Zip Code

Phone Number

Format: (000) 000-0000.

Date of Birth

Date

How did you hear about our program?

If you were referred, name of person who referred you.

Preferred Method Of Contact

Awaken...Discover where you are and where you want to be!

Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)

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Describe where you would like to be in your Health...

0/330

Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)

0/330

How would your life be different emotionally, mentally, physically when you have achieved your health goals?

0/330

Medical

Are You Pregnant

Are You Nursing

If yes, how old is your baby

Do you have the following

Are you taking anything, have allergies, or do you have any conditions that could influence the system we design for you?

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Are you taking any medications for:

Are you taking other medications or have other medical conditions that could influence which program we choose?

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*Lithium: The 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 levels while the Client is on the Program and adjust medication.
***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.

SLEEP

How many hours of sleep do you typically get?

What time do you typically go to bed?

What time do you typically wake up?

How is your quality of sleep?

Do you wake up feeling rested?

HYDRATION

How much water do you drink each day?

How much Coffee?

How much Soda?

How much Tea?

How much Alcohol?

0/50

MOTION

How would you rate your energy level? (on a scale of 1-10)

How many times a week do you exercise?

What physical activities do you participate in?

Are there things you can't do that you would like to be able to?

STRESS

How would you rate your stress level? (on a scale of 1-10)

What do you do for work?

How much do you enjoy what you do?

Are there other stressors in your life?

EATING HABITS

How many meals per day do you eat?

When do you eat your first meal?

When do you eat your last meal?

Do you snack between meals?

What kind of snacks?

How many times a week do you eat out?

Where?

WEIGHT

Current Weight

Goal Weight

Height

Have you tried to lose weight before?

What has been most difficult about losing/maintaining weight in the past?

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SURROUNDINGS

How healthy would you rate your surroundings? (on a scale of 1-10)

Do you have healthy & active friends, supportive family, keep junk food in the house, etc?

Is there anyone in your life who would like to get healthy with you?

Have you utilized in the past or are you currently utilizing one of the following medically supported weight loss tools like Bariatric surgery, GLP1 shots, and/ or pills? (check all that apply)

On a scale of 1-10 (10 meaning ready to go!), how motivated are you to start working on your health goals?

The program I coach is a program that addresses lifestyle & habit changes in the form of nutritional and behavioral support. However, we have a combination therapy option available to those who desire BOTH medically supported weight loss in conjunction with lifestyle transformation. Do you desire to discuss if combination therapy would be a good fit for you?

Let's Design Your System