HEALTH ASSESSENT

Introductions & Setting Expectations for Meeting

Health Assessment

Full Name *

Email *

Address *

City *

State *

Postal code *

Phone *

Date of birth

Preferred Contact Method

Phone
Email
SMS Text
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It’s great speaking with you today and I’m excited to see if I can assist you with your goals. Before we can determine if one of our Programs is right for you, I’d like to ask you a few questions to learn about you and your health goals. Does that sound good?

Awaken...Discover where you are and where you want to be!

Describe where you are in your health now

Describe where you would like to be in your health. *

Please describe WHY you are interested in getting healthy *

When was the last time you remember feeling your best in your health or being at your ideal weight or size *

Medical

Are you Pregnant?

Yes

No

Are you nursing?

Yes

No

If yes, how old is your baby?

Any food allergies that I should be aware of

Do you have the following

Diabetes - Type 1

Diabetes - Type 2

High Blood Pressure

Gout

Are you taking any medications for:

Diabetes

High Blood Pressure

Lithium*

Thyroid

Coumadin (Warfarin)

*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

Are you taking other medications or have other medical conditions that could influence which program we choose? *

Sleep

SLEEP & ENERGY

How many hours of sleep do you get in a typical night?

What time do you typically go to bed?

What time do you typically wake up?

How is your quality of sleep?

Do you wake up feeling rested?

Hydration

How much water do you drink each day?

How much Coffee?

How much Soda?

How much Tea?

How much Alcohol?

Motion

How would you rate your energy level? (on a scale of 1-10)

How many times a week do you exercise?

What physical activities do you participate in?

Are there things you can't do that you would like to be able to

Stress

How would you rate your stress level? (on a scale of 1-10)

What do you do for work?

How much do you enjoy what you do?

Are there other stressors in your life?

Eating Habits

How many meals per day do you eat?

When do you eat your first meal?

When do you eat your last meal?

Do you snack between meals?

What kind of snacks?

How many times a week do you eat out?

Where do you eat out?

Weight

Current Weight

Goal Weight

Height

Have you tried to lose weight before?

What has been most difficult about losing/maintaining weight in the past? *

Surroundings

How healthy would you rate your surroundings? (on a scale of 1-10)

Do you have healthy & 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?

Thank you for sharing. Now, I'd like to tell you how our Program could help you achieve your goals.