HEALTH SURVEY - STORMS

Your Current Reality and Goals

Mike and Glori Storms
Name*

First NameLast Name
Date*

MonthDayYear
Today's date
Email*
example@example.com
Age:
Phone Number*
Please enter a valid phone number.
Address

Street Address

CityState / Province

Postal / Zip Code
Preferred method of contact:*

CallEmailText
How did you hear about our program?
Medical
Are you pregnant?*

YesNo
Are you nursing?

YesNo
If yes, how old is your baby?
Do you have any food allergies? If yes, please describe:
Sleep
How many hours of sleep do you usually get?*
Do you wake up feeling rested?
Hydration
How much water do you drink a day?*
How much coffee do you drink in a day?
What other beverages do you consume?

coffeesodateaalcoholfruit juice
Movement
How many times a week do you exercise?
What kind of exercise do you participate in?
Are there things you would like to do, that you currently are not physically able to do?
How would you rate your daily energy level?
Stress
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
How would you rate your stress level?
Eating Habits
When do you eat your first meal?*
When do you eat your last meal?
How many meals per day do you eat?
Do you snack? If yes, on what?
How often do you eat out in a week?
Where do you eat out at?
Weight
Current weight (if you wish to share):
What is your height?*
In a perfect world, if you could not fail, how many pounds would you want to lose:*
Have you tried to lose weight before?
If yes, what have you found most difficult about losing weight in the past?
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that is part of your goal)?
On a scale of 1 to 10, how serious are you about taking the next step in your health journey?
Please describe your personal “WHY” the reasons for becoming a healthier version of yourself. What is your main motivation? Improve Relationships, activities, how you feel about yourself , less pain, more energy, etc.
Is there anyone in your life who would like to get healthy with you? Spouse, best friend, neighbor, co worker?
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Your Current Reality and Goals

Medical

Sleep

Hydration

Movement

Stress

Eating Habits

Weight