Health Assessment

Lucky Starrs, Independent Certified Optavia Coach

First Name *

Last Name *

Email *

Address *

City *

State *

Postal code *

Phone *

Birth Date

How Did You Hear About Our Program

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

Describe where you are in your Health now... (weight, sleep, stress, energy, etc)

Describe where you would like to be in your health...

Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)

When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)? *

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MEDICAL

Sex

Male

Female

If Female, Are You Nursing?

Yes

If yes, how old is your baby?

Do you have any the following?

Diabetes - Type 1

Diabetes - Type 2

High Blood Pressure

Gout

Are there any food or other allergies that I should be aware of?

*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.

Are you taking other medications or have other medical conditions that could influence which program we choose?

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SLEEP

How many hours of sleep do you typically get?

What time do you typically go to sleep?

What time do you typically wake up?

How is your quality of sleep?

Do you wake up feeling rested?

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HYDRATION

How much water do you drink each day?

How much Coffee?

How much Soda?

How much Tea?

How much Alcohol?

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MOTION

How would you rate your energy level? (on a scale of 1-10)

How many times a week do you exercise?

What physical activities do you participate in?

Are there things you can't do that you would like to be able to?

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STRESS

How would you rate your stress level? (on a scale of 1-10)

What do you do for work?

How much do you enjoy what you do?

Are there other stressors in your life?

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EATING HABITS

How many meals per day do you eat?

When do you eat your first meal?

When do you eat your last meal?

Do you snack between meals?

Yes

What kind of snacks?

How many times a week do you eat out?

Where?

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WEIGHT

Current Weight

Goal Weight

Height

On a scale of 1-10 (10 meaning ready to go!), how motivated are you to start working on your health goals?

What has been most difficult about losing/maintaining weight in the past?

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SURROUNDINGS

How healthy would you rate your surroundings? (on a scale of 1-10)

Do you have healthy & active friends, supportive family, keep junk food in the house, etc?

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

Yes

Their First Name

Their Last Name

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