Name*

Date*

Date

Address*

Street Address

Street Address Line 2

City State

Zip Code

Phone*

How did you hear about our program?

Email*

example@example.com

Date of Birth

Date

Preferred Method Of Contact

Text Call Email

What would you like to accomplish with your health? (Weight loss, improved sleep, better response to stress, etc)*

0/100

What is your main motivation for wanting to make changes to your health?(Relationships, activities, how you will feel, etc)*

0/100

Can you tell me about a time in your life when you were healthier? What has changed between then and now?*

0/100

Tell me about your health: Do you have any medical conditions that could influence which Program we choose?**

0/100

Are you Pregnant

Yes No

Are you Nursing

Yes No

If yes, how old is your baby?

Are you taking any medications for:

What Other Medications are you taking?

¹Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
²Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
³Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication

Do you have the following:

What food or other allergies do you have?

How many hours of sleep do you typically get?

What time do you typically go to bed?

What time do you typically wake up?

Quality of Sleep?

Do you wake up feeling rested?

How much water do you drink each day?

Coffee

Soda

Tea

Alcohol

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

What physical activities do you participate in?

How many times a week do you exercise?

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

How would you rate your stress level?

What do you do for work?

How much do you enjoy what you do?

Are there other stressors in your life?

How many meals per day do you eat?

When do you eat your first meal?

When do you eat last meal?

Do you snack between meals?

What kind of snacks?

How many times a week do you eat out?

What restaurants do you eat at?

Current Weight

Goal Weight

Height

Have you tried to lose weight before?

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

0/100

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?

HEALTH ASSESSMENT

Medical

DAILY ROUTINE & HABITS

HYDRATION

MOTION

STRESS

EATING HABITS

WEIGHT

SURROUNDINGS