Health Assessment

First Name

Last Name

Email *

Address

City

State

Postal code

Phone *

How did you hear about our program?

What do you hope to accomplish with your health?

Weight Loss

Confidence

Energy

Better Sleep

Feel Better

Be more present with my family and friends

Peace of mind about my health

Preferred Method of Contact

Text

Call

Birth Date

MOTIVATION & GOALS

Tell me about where you are now with your health. (weight, sleep, stress, energy, medical concerns, etc.)

Describe where you would like to be in your health.

When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)? *

Describe WHY you are motivated to get healthy. What is your main motivation? What would the confidence, energy, or mental clarity you'll gain change for you?

MEDICAL

Gender

Male

Female

If female, are you nursing?

Yes

Medical Info

Diabetes

High Blood Pressure

High Cholesterol

Thyroid*

Lithium**

Coumadin (Warfarin)***

If yes, how old is your baby?

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

Are you currently using or interested in learning more about medical weight loss solutions such as GLP-1

I'm utilizing medically supported weight loss such as GLP-1

I'm not using GLP-1 but I am interested

I am not interested in Medically Supported Weight Loss Solutions

*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.

SLEEP

How many hours of sleep do you typically get?

What time do you typically go to sleep?

How is your quality of sleep? Do you wake up feeling rested?

What time do you typically wake up?

HYDRATION

How many ounces of water do you drink each day?

How much coffee and/or soda do you drink each day?

How many alcoholic drinks do you consume in a day/week?

MOTION

How many times do you exercise each week?

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

Which physical activities do you enjoy and/or participate in?

Are there any activities you can't do that you would like to be able to?

LIFE & STRESS

How would you describe your stress level on average?

What do you do for work and fun? How much do you enjoy your current work?

EATING HABITS

How many meals do you eat per day?

What types of restaurants do you typically eat out at?

About what time do you usually eat your first and last meals?

Do you snack between meals?

Yes

How many times a week do you dine out?

If you are a snacker, what times of day and what types of snacks do you choose?

WEIGHT

Current Weight

Have you tried to lose weight in the past? What has been most difficult?

Goal Weight

Who might be a stumbling block to your progress?

Height

Who will support you in this journey?

On a scale of 1-10, how motivated are you to start working on your health goals?

Is there anyone who would like to get healthy with you?