HEALTH CHECK UP

HEALTH CHECK UP

This form should take 5-10 minutes to complete
First & Last Name*
Email*
example@example.com
Phone*
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.)?*
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?*
DAILY ROUTINE & HABITS
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?*
On a scale of 1-10, what is your energy level throughout the day?*
MOTION
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?*
FOOD & HYDRATION
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?
What would you consider to be a healthy weight for you?*
SURROUNDINGS
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?
Should be Empty:

DAILY ROUTINE & HABITS