Health Assessment

First Name

Last Name

Phone *

Email *

City

State

What is your main motivation to improve your health?

When was a time in your life when you were healthier? What changed?

Imagine being at the right weight for your body and knowing you are healthy and strong. How would you feel? What would be be able to do? (Be specific: less stress, more energy, better sleep, travel, hiking, playing with your kids or grandkids at the park, ride rollercoasters, etc.)

What is your height?

What is the Minimum amount of weight you want to lose?

What is the Maximum amount of weight you want to lose?

Have you tried to lose weight in the past?

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

Do you have any allergies or medical conditions?

Women: Are you pregnant or nursing?

Have you tried any weight loss programs in the past? Which ones?

Can you think of anything else I should know about your health?

On a scale of 1-10 with 10 being Highly Motivated and 1 being Not Motivated at All, how motivated are you to make changes to improve your health?

What are you most afraid of regarding your health goals ... what do you think could keep you from reaching them?

What would be the best outcome of this health journey for you?

I have good news for you! You absolutely CAN reach your goals and I am here to help you. Soon you'll be looking back from a place of success and you'll be so glad you took this first step!

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