Mary and a Happy New You Health Evaluation Form
Name
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Phone
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Format: (000) 000-0000.
Email
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Preferred Method of Contact
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Address
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Street Address
City
State / Province
Postal / Zip Code
Referred From?
STEP 1: AWAKEN
1. What would you like to accomplish with your health? This could be weight-loss, improved sleep, better response to stress, etc.
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2. What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
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3. Can you tell me about a time in your life when you were healthier? What has changed between then and now?
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4. Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?
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5a. Are you Pregnant?
No
Yes
5b. Are you Nursing?
No
Yes
6. Are you taking any medication for:
Diabetes
High Blood Pressure
Lithium*
Thyroid
Coumadin (Warfarin)
Other
7. Do you have any of the following:
High Blood Pressure
Diabetes - Type 1
Diabetes - Type 2
Gout
Gluten Allergy or Intolerance
Soy Allergy or Intolerance
Food Allergy (Medically Diagnosed)
Other
*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.
STEP 2: DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
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How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
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MOTION
How would you describe the quantity & quality of the activity you do each week?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
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What types of physical activity do you enjoy?
MIND
On a scale of 1-10, how fulfilled are you?
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On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?
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On a scale of 1-10, how much do you enjoy what you do?
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FOOD & HYDRATION
How many meals and snacks do you eat per day?
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When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?
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Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
WEIGHT MANAGEMENT
Age
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Height
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How much do you currently weigh?
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What would you consider to be a healthy weight for you?
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Have you tried to lose weight in the past?
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What has been difficult for you about losing and maintaining weight?
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SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (This includes: healthy friendships, supportive family, keep junk food in the house, etc
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Is there anyone in your life who would like to get healthy with you?
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Is there anything else you think I should know about your health?
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Submit
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