Name
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First Name
Last Name
Email
*
Phone
*
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What would you like to accomplish with your health? This could be weight-loss, improved sleep, better response to stress, etc.
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc.
Can you tell me about a time in your life when you were healthier? What has changed between then and now?
Tell me about your health: Do you have any allergies or medical conditions that could influence which program we choose?
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking any medication for any of the following?
Do you have any of the following? Select those that apply.
How many hours of sleep do you get in a typical night?
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
1
2
3
4
5
6
7
8
9
10
How many hours a day do you sit?
How many days a week do you exercise?
0
1
2
3
4
5
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7
What types of physical activity do you enjoy?
What area of your life tends to be the biggest stress for you?
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?
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2
3
4
5
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9
10
How many meals and snacks do you eat per day?
When do you eat your first meal of the day?
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?
Please provide your current weight and height.
How much do you currently weigh?
Is there anything else you think I should know about your health?
