Health Assessment
Hello, friend! This is an exciting step on your journey to optimal health! We are so grateful for the opportunity to partner with you and provide support along the way. To help us get started, please take a few moments and thoughtfully complete the questions below. We are looking forward to learning more about you, your health goals, and any individual needs you may have. We will be in touch soon, but if you need anything in the meantime please don't hesitate to reach out at ntohs30@gmail.com
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Who referred you?
friends, social media etc.
Awaken!
Discover where you are and where you want to be!
Share a bit about your life, family, hobbies, etc.
In relation to your health, if you knew failure wasn't an options, what would you want to create? *
What's your primary motivation for wanting to make a change in your life? (i.e. relationships, activities, confidence, longevity, etc.) *
When was the last time you remember feeling your best in health or being at your ideal weight/size (if that's part of your goal)? *
STEP 2
MEDICAL
Are you pregnant?
Yes
No
Do you have the folllowing?
Diabetes Type 1
Diabetes Type 2
High Blood Pressure
Gout
Are there any other food or other allergies I should be aware of?
Do you have or are you taking medications for:
*High Blood Pressure
Diabetes - Type 1
Diabetes - Type 2
Gout
Gluten Allergy or Intolerance Soy
Allergy or Intolerance
Food Allergy (Medically Diagnosed)
None
Are you taking other medications or do you have other medical conditions that could influence what program we choose? *
*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 & ENERGY
How many hours of sleep do you typically get nightly? *
What time do you typically wake up?
What time do you typically go to bed?
How is your quality of sleep? *
Do you wake up feeling rested? *
On a scale of 1-10, what is your energy level throughout the day?
MOTION
How would you describe the quantity & quality of the activity you do each week?
What physical activities do you participate in? *
How many days a week do you exercise? (0 - 7 days)
MIND
On a scale of 1-10, how fulfilled are you?
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?
On a scale of 1-10, how much do you enjoy what you do?
FOOD & HYDRATION
Do you snack between meals? If yes, what kind of snacks?
How many times a week do you eat out? And where?
How many meals do you eat per day?
When do you eat your first meal of the day?
How many ounces of water do you drink per day? *
How much coffee?
How much soda?
How much tea?
How much alcohol?
Weight Management
Height *
Current Weight *
Goal Weight *
Have you tried to lose weight before? *
What has been most difficult about losing/maintaining weight in the past? *
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 *
Do you have healthy & active friends? Supportive family? Do they keep junk food in the house? Do you have any other concerns? *
Is there anyone in your life who you have "dieted" with or is working on their own health and might like to have extra support? *
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