HEALTH ASSESSMENT FORM

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Please fill out this form as completely and accurately as possible. Your information will be kept confidential and used to create a personalized health plan for you.

• Full Name: ___________________________________________
• Date of Birth: _________________________________________
• Gender: _____________________________________________
• Phone Number: ________________________________________
• Email Address: ________________________________________

• Do you have any chronic conditions (e.g., diabetes, heart disease, asthma)?     
• Yes / No
• If yes, please specify: ______________________________________________________________

• Yes / No
• If yes, please list: _________________________________________________________________

• Do you have any allergies (food, medication, environmental)?
• Yes / No
• If yes, please specify: ______________________________________________________________

• Have you had any surgeries or major illnesses in the past 5 years?
• Yes / No
• If yes, please describe: _____________________________________________________________

• Do you have any injuries or physical limitations?
• Yes / No
• If yes, please specify: ______________________________________________________________

• Do you have upper respiratory issues?
•  Yes/No
• If yes, please specify: ______________________________________________________________

• Do you have digestive issues? 
• Yes /No
• If yes, please specify:_______________________________________________________________

• Do you have pain regularly? 
• Yes / No
• If yes, please specify:-_______________________________________________________________

• How often do you have a bowel movement?    ____________           Do you have constipation?      __________

• How would you rate your current stress levels?
• Low / Moderate / High

• How many hours of sleep do you typically get per night?
• Less than 5 / 5-7 / 7-9 / More than 9

• At what time do you go to sleep? _______________________________________________________

• How often do you exercise?
• Never / Occasionally / Regularly
• If regularly, what type of exercise do you do? _______________________________________________

• Do you smoke?___________________________________________________________________
• Yes / No / Occasionally

• Do you consume alcohol?       Yes / No / Occasionally

• Do you follow a specific diet or eating plan?
• Yes / No
• If yes, please describe: ______________________________________________________________

• How many meals do you eat per day? ___________________________________________________

• How many snacks do you eat per day? __________________________________________________

• Do you have any dietary restrictions or food intolerances?
• Yes / No
• If yes, please specify: ______________________________________________________________

• How often do you eat out or order takeout per week?
• Never / Once a week / Multiple times a week / Daily   

• What does "Clean Food" mean to you?__________________________________________________

• Do you use any supplements or vitamins?
• Yes / No
• If yes, please list: _________________________________________________________________

• What is your take on "Organic" foods____________________________________________________

• What are your primary health and wellness goals?__________________________________________

• _____________________________________________________________________________                                             
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• What motivates you to pursue these goals?_______________________________________________
  
• Have you tried to achieve these goals in the past?
• Yes / No
• If yes, what worked and what didn't? ____________________________________________________

• What obstacles do you anticipate in achieving your goals?____________________________________
  
• How Dedicated are you to this process?__________________________________________________
• Signature: _________________________________________
  Date: _____________________________________________

Thank you for completing this health assessment form. Once received, I will review this information and use it to develop a Taylor-Made plan to help you achieve your wellness goals.  "LET"S GO"