HEALTH ASSESSMENT

Health Assessment

Marty & Paula Darracott - Certified Independent Optavia Health Coaches
Exploring YOUR Health Journey

to see if this opportunity would be a good fit for you
First Name*
Last Name*
Today's Date*

MonthDayYear
Date
Gender*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
Preferred Method Of Initial Contact*

TextCallEmail
I would love to hear what you would like to accomplish with your health.*

Weight LossImproved SleepReduce StressMore EnergyPain Relief
How did you hear about our health program?
Social Media post? Individual? (If so, Please insert the name of the individual)

Describe your current state of health and wellness*

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
My Current Weight
My Current Situation with Resting through the night
My Current Stress Level
My Current Energy Level
My Current Financial Situation

On average, how many times per week are you eating out? Please include your number of meals out at restaurants, vending machines, gas station stops, drinks/snacks at coffee shops, etc..)*
How many times per week do you exercise? What does that consist of? *
Are you currently taking medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroid*Lithium**Coumadin (Warfarin)***
*Thyroid Medications: Your healthcare provider may wish to monitor thyroid hormone levels while client is on program and adjust medication accordingly

**Lithium: Your healthcare provider may wish to adjust the frequency of lab work for you as a client and monitor those results closely

***Coumadin (Warfarin): Your healthcare provider may wish to review food choices, adjust the frequency of lab work for you as a client and monitor those results closely
Are you taking any other medications or have any other medical conditions?*
Are you pregnant?

YesNo
If yes, how old is your baby?
Height?*
Current weight?*
Goal weight?*
On A Scale Of 1-5, 5 Being All In, What Is Your Level Of Motivation To Make A Change?*

1

2

3

4

5

1 is None At All, 5 is All In
Should be Empty:

Health Assessment