MyHealthyLife Assessment

Name *

First

Last

Email *

Today's Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Preferred Method of Contact *

Who referred you?

If you were referred, name of person who refrred you.

AWAKEN...... Discover where you are and where you want to be!

I would love to hear what you would like to accomplish with your health. (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?*

MEDICAL

Are you Pregnant? *

Are you nursing? *

How old is your baby?

Are you taking any medications for:

Diabetes
High Blood Pressure
Lithium*
Thyroid†
Coumadin (Warfarin)‡
Other medications

*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.

Other Medication: List Here *

Do you have the following

High Blood Pressure
Diabetes Type I
Diabetes Type II
Gluten Intolerance or Sensitivity
Soy Allergy or Intolerance
Food Allergies
Other

Other: List here *

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SLEEP & ENERGY

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?

What time do you typically wake up? *

What time do you typically go to bed? *

MOTION

How would you describe the quantity & quality of the activity you do each week?

How many hours a day do you sit?

How many days a week do you exercise? (0 - 7 days)

MIND

On a scale of 1-10, how fulfilled are you?

On a scale of 1-10, how much do you worry?

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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FOOD & HYDRATION

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?

WEIGHT MANAGEMENT

How tall are you?

How much do you currently weigh?

What would you consider to be a healthy weight for you?

Have you tried to lose weight in the past?

What has been difficult for you about losing and maintaining weight?

On a scale of 1-10, how healthy would you rate your surroundings?

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

Is there anything else you think I should know about your health?