Health Assessment
Roy and Dawn Brewster
Your Name
Email
example@example.com
Preferred Method of Contact
Phone
I would love to hear what you would like to accomplish with your health. Weight loss, improved sleep, better response to stress, etc
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
3 Can you tell me about a time in your life when you were healthier? What has changed between then and now?
Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?
Are you nursing?
Are you pregnant?
Are you taking any medications for or have had any of the following?
High Blood Pressure
Diabetes
Diabetes Type I
High Blood Pressure
Diabetes Type II
Lithium
Gout
Thyroid
Gluten Intolerance or
Coumadin (Warfarin)
Other medications:
Soy Allergy or
Food Allergies
Other
SLEEP & ENERGY
On a scale of 1-10, how would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
MOTION
How would you rate the quantity and quality of activity you do each week?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)
What types of physical activity do you enjoy?
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
How many meals and snacks do you eat per day?
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?
Do you drink and other beverages? Coffee, soda, alcohol, tea, etc. If so, how often and how much?
WEIGHT MANAGEMENT
Are you comfortable sharing your age?
How tall are you?
How much do you currently weigh?
What would you consider to be a healthy weight for you?
Have you tried to lose weight in the past?
What has been difficult for you about losing and maintaining weight?
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (Supportive family, junk food in the house, etc)
Is there anyone in your life who would like to get healthy with you?
Is there anything else you think I should know about your health?
Date
/
Month
/
Day
Year
Date
How did you hear about us?
Client Referral
24 hr Fitness
Website
Other
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