Awaken Potential
Health Evaluation
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.Right now, how would you describe your overall health? Physical, mental, energy, self confidence..
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2. If you knew you couldn't fail, what would your health/weight goals look like? This could be weight-loss, improved sleep, better response to stress, etc.
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3. What would you change about your life right now to make it better? I get some deep responses here and I want you to know this is totally confidential. I knew my health and my debt was in trouble before I started getting healthy. Both were big reasons I ate and drank, so I get it. Share away...
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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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4a. Are you Pregnant?
No
Yes
4b. Are you Nursing?
No
Yes
5. Are you taking any:
Diabetes
High Blood Pressure
Lithium*
Thyroid
Coumadin (Warfarin)
Other
6. 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 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?
How many pounds away are you from feeling confident?
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Have you tried to lose weight in the past? Lord knows I tried more times than I can count
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What has been difficult for you about losing and maintaining weight?
On a scale of 1-10 how committed are you to getting to your health goals?
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SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surrounds? (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?
Are you experiencing hair loss or dry texture? Is it post Covid related? Hormonal? Ozempic? Or not sure?
I 100% believe in this program and its ability to help everyone incorporate healthy habits into their daily lives. Your commitment is the key to its success. While the journey might not always be easy, the most meaningful aspects of life often come with challenges. I know you can lose the weight with my support, but remember, your effort will play a significant role in your progress. How does that make you feel? A bit nervous? That’s completely normal! I felt the same way at first. Then I realized I could take charge of one aspect of my life, and that’s what inspired me to move forward. How do you feel about that now? I’m really looking forward to working together!
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