HEALTH SURVEY

Please fill out this health survey

NAME
FIRST NAME:
LAST NAME:
DATE:
EMAIL:
PHONE NUMBER:
ADDRESS:
STREET ADDRESS:
STREET ADDRESS LINE 2:

CITY:
STATE\PROVINCE:
POSTAL\ZIP CODE:
PREFERRED CONTACTS:
PHONE CALL:
PHONE MESSAGE:
EMAIL:
OTHER:
BIRTH DATE:
AGE:
GENDER:

MEDICAL

DO YOU HAVE ANY OF THE FOLLOWING?

HIGH BLOOD PRESSURE:
DIABETES-TYPE 1:
DIABETES-TYPE 2:
GOUT:

ARE YOU TAKING ANY MEDICATIONS FOR?

DIABETES:
HIGH BLOOD PRESSURE:
HIGH CHOLESTROL:
THYROID:
LITHIUM:
COUMADIN(WARFARIN):

ARE YOU PREGNANT?

YES:
NO:
N\A:

ARE YOU NURSING?

YES:
NO:

DO YOU HAVE ANY FOOD ALLERGIES?

YES:
NO:
PLEASE DESCRIBE:

BMI
HEIGHT IN INCHES:
WEIGHT IN LBS:

BODY MASS INDEX

WHAT IS YOUR CURRENT BMI NUMBER?

WHAT IS THE BMI VALUE FOR THE WEIGHT

YOU WANT TO MAINTAIN AT?
SLEEP
IN GENERAL, WHAT TIME DO YOU GET TO
BED?
IN GENERAL, WHEN DO YOU WAKE UP?

ON AVERAGE, HOW MANY HOURS OF SLEEP

DO YOU GET?
DO YOU WAKE UP FEELING RESTED?
YES:
NO:
OTHER:
PLEASE DESCRIBE OF:
HOW IS THE QUALITY OF YOUR SLEEP?

HYDRATION:
IN A DAY, HOW MUCH WATER DO YOU DRINK
USUALLY?
IN A DAY, HOW MUCH COFFEE DO YOU DRINK
USUALLY?
IN A WEEK, HOW MUCH ALCOHOL DO YOU
CONSUME USUALLY?

MOVEMENT:
HOW MANY TIMES PER WEEK DO YOU
EXERCISE?
WHAT KIND OF EXERCISE DO YOU
PARTICIPATE IN?
ARE THESE THINGS YOU WOULD LIKE TO DO
THAT YOU ARE CURRENTLY ABLE TO?
HOW WOULD YOU RATE YOUR DAILY ENERGY
LEVEL?
0
1
2
3
4
5
6
7
8
9
10
STRESS
WHAT DO YOU DO FOR WORK?
DO YOU ENJOY WHAT YOU DO?
ARE THERE ANY OTHER STRESS IN YOUR LIFE?

RATE YOUR OVERALL STRESS LEVEL?

1
2
3
4
5

EATING HABITS
WHEN DO YOU TAKE YOUR FIRST MEAL?
WHEN DO YOU EAT YOUR LAST MEAL?
HOW MANY MEALS PER DAY DO YOU EAT?
DO YOU SNACK, IF YES, WHAT DO YOU SNACK ON?