HEALTH ASSESSMENT
This form should take 5-10 minutes to complete
First & Last Name
Email
example@example.com
Phone
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Method of Contact
Text, phone call, email, FaceTime/Zoom
What would you like to accomplish with your health (weight loss, improved sleep, better response to stress, etc.)?
What is your primary motivation for wanting to make changes to your health (relationships, activities, how you will feel, etc.)?
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? Are you currently pregnant or nursing?
Are you currently taking any medications?
Are you pregnant?
NO
Yes
Are you nursing?
NO
Yes
If yes, how old is your baby?
Are you taking any medications for:
Diabetes
High Blood Pressure
Lithium
Thyroid
Coumadin (Warfarin)
Other
Not Applicable
Do you have any of the following:
High Blood Pressure
Diabetes Type I
Diabetes Type II
Gout
Gluten Intolerance/Sensitivity
Soy Allergy/Intolerance
Food Allergies
Other
Not Applicable
DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
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 describe the quantity and 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)
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?
My current employment is:
Very fulfilling
Pays the bills, but I don't love it
Ready for a career change
Other
Are you interested in learning more about helping others with their health while also earning a great income?
Yes, very interested
I am curious
Not at this time
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 other beverages (coffee, soda, alcohol, tea, etc.)? If so, how often and how much?
WEIGHT MANAGEMENT
What is 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?
YES
No
If yes, what has been difficult for you about losing and maintaining the weight?
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (Do you have healthy and active friends, supportive family, keep 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?
Submit
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