Health AssessmentPlease complete this free, no obligation health information form, so we can find the plan that will work best for you. Basic Info Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Country * United States Singapore Hong Kong Military Other Time Zone * Facebook/ Instagram Name How did you know to reach out to me? General Health & Lifestyle Rate your overall health. * 1 being "completely unhealthy". 10 being "best health of my life"! 1 2 3 4 5 6 7 8 9 10 Do you have any food allergies? * Do you have any medical conditions? * What medications or supplements do you currently take? * In one word, how would you describe your health? * How much weight do you need to lose? * Does that number represent you getting you to your healthiest self, or does that number just seem like the most achievable number? * Healthiest Self Just Achievable When was the last time you were at that weight? * What has changed since then? * What habits do you struggle with? * Late night snacking, stress eating, poor habits, overeating, etc. What do you do for work? * Day-to-day What time do you wake up on a typical day? * What time do you go to bed on a typical day? * What times do you eat on a typical day? * Briefly describe your meals on a typical day. * Ex. Donuts for breakfast, fast food for lunch, take out for dinner, etc. How much water do you drink in a typical day? * 0-16 ounces 17-36 ounces 37-60 ounces 61-100 ounces More than 100 ounces Do you exercise? * Yes No If you exercise, what kind of exercise do you do? How often do you eat or buy take-out? * How much would you say that you spend on food including groceries, take out, Starbucks, snacks, etc? * The average person spends $20-$26/ day on food. Are you somewhere in that range? How do you learn best? * By reading printed material? By listening to podcasts? By watching videos? Your Motivation Can you tell us 1 - 3 reasons why this change is important to you? How would losing weight and getting healthy change your life? * Rate you current stress level. * 1 being "stress free". 10 being "unbearable". 1 2 3 4 5 6 7 8 9 10 Rate your current energy level * 1 being "no energy". 10 being "bursting at the seams". 1 2 3 4 5 6 7 8 9 10 Rate your readiness to get healthy and lose the weight. * 1 being "not ready". 10 being "ready to start yesterday". 1 2 3 4 5 6 7 8 9 10
