Professional Documents
Culture Documents
Assessment Sheet
Assessment Sheet
Name: Date:
Email Address: Phone:
GOALS:
1._________________________________________________________________
2._________________________________________________________________
3._________________________________________________________________
REALITY
How often do you have your blood work screened at your doctor’s?_____________________________________
Do you have family history of: Heart Disease Diabetes High Cholesterol
Hypertension Cancer
Exercise
History:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Nutrition Habits:
# of Meals/Day:____________
Breakfast:_____________________________________________________________________________________
Snack:________________________________________________________________________________________
Lunch:________________________________________________________________________________________
Snack:________________________________________________________________________________________
Dinner:_______________________________________________________________________________________
Snack:________________________________________________________________________________________
Vitamins/Supplements:__________________________________________________________________________
Injuries or
Limitations:____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Obstacles or
Challenges:____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________