Client Weekly Health Check-In Form
Check-In Date & Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Name
First Name
Last Name
Age
Gender
Male
Female
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height (cm)
Weight (kg)
What are you health goals this week?
What kind of lifestyle do you have?
Sporty
Active
Semi-active
Sedentary
How many hours of sleep do you get daily?
How often do you exercise every week?
Do you smoke?
Yes
No
What type of a smoker are you?
Social smoker
Anxious smoker
Skinny smoker
Addicted smoker
Do you drink alcohol?
Abstainer
Social drinker
Binger (High risk)
Dependent (High risk)
Do you feel any not normal within your body physically?
Yes
No
Please tell us more about it
Review of Body System
Rows
Normal
Abnormal
Remarks
Gastrointestinal
1
2
Respiratory
3
4
Cardiovascular
5
6
Neurological
7
8
Dermatological
9
10
Musculoskeletal
11
12
Urinary
13
14
Reproductive
15
16
Metabolic
17
18
Endocrine
19
20
Comments, suggestions, or feedback
Patient Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: