HEALTH ASSESSMENT

(Please print all information Thank you!)

(Please circle appropriate Title and Marital Status)

Dr. / Mr. /Mrs. / Ms. / Miss

ALSO: S / M / W / D / Other

Last Name_______________________________________ First Name _________________________________ MI ___________

Address __________________________________________________________________________________________________
City ________________________________________________________ State _____________ Zip Code ___________________
Name you like to be called _________________________________ Birthdate __________________ # of Children _____________
Height ___________________________ Weight _____________________________ Home Phone ________________________
Work Phone ____________________ Cell Phone ____________________ Cell Phone Carrier _____________________________
Your Email _________________________________________________________________
Occupation _________________________ Employer ______________________________________________________________
Address _________________________________________ City _________________________ State _______ Zip ____________
To help better understand and pinpoint your optimal plan, we ask that you answer the following questions. Fill in the blank next to
the term that best describes how you feel under certain conditions and different circumstances during the day.
Parent name / responsible party (for those under 18 yrs. old) _____________________________________________________

I.

General Health

1) How do you describe your general health?

____ Excellent

____ Good

____ Poor

2) Do you catch colds easily & frequently? ____ Yes ____ No - If yes, do they last longer than 3 days on average? ____ Yes ____ No
3) Are you being treated for any illnesses or had surgery within the last 3 months? ____ Yes ____No - If Yes, please explain:

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4) Are you allergic to:

Inhalants? ____ Yes ____ No

Foods? ____ Yes ____ No

If Yes, please explain:

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5) Have you ever been diagnosed as having any of the following?
Kidney Disorder ____
Liver Diseases ____
Viral Infection (e.g. EBV, Herpes) ____
Anemia ____
Genetic Disorders ____ Yeast Infection (e.g. Candidiasis) ____
Hair Loss ____ Skin Problems ____
Bursitis ____
Hereditary Diseases ____
If yes, please specify:

Diabetes ____
Arthritis ____

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________________________________________________________________ When? ___________ How Long? ______________
6) Does your family history include any of the following conditions?
Heart Disease ____
Cancer ____
Diabetes ____
High Blood Pressure ____ Depression/Schizophrenia ____
Genetic Disorders/Hereditary Diseases (e.g. PKU, etc.) ____
If yes, please specify:

__________________________________________________________________________________________________________
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7) Please list any medications or nutritional supplements you are presently taking:

__________________________________________________________________________________________________________
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II.

Energy/Mood Levels:

1) Do you experience frequent mood swings during the day, for example, happy to depressed?
____ Yes
____ No
2) Do you have trouble relaxing in the evening?
____ Yes
____ No
3) Do you experience difficulty in falling asleep, taking more than 15 minutes?
____ Yes
____ No
4) Do you wake up feeling sluggish and fatigued?
____ Yes
____ No
5) Do you experience difficulty concentrating or remembering daily events or things to do?
____ Yes
____ No
6) Do you become impatient and anxious over trivial matters easily?
____ Yes
____ No
7) Are you easily fatigued by your daily routine?
____ Yes
____ No
8) Are you under a tremendous amount of stress, either personally or professionally
____ Yes
____ No
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III.

Eating Habits

1)

After eating a meal high in protein, do you feel:

(High protein foods: meat, fish, chicken, dairy)

2)

Does a carbohydrate meal leave you feeling too relaxed or sleepy?

(High carbohydrate foods: potato, pasta, rice, pastries, sweets)

3)

Do you tend to snack:

When you are nervous?
When you are depressed?
In the evening?

4)

____ Yes
____ Yes
____ Yes

How often do you eat the following:

Dairy Products:
____ Daily
Red Meat:
____ Daily

____ No change

____ No
____ No
____ No

On foods high in salt?

On foods high in sugar?

____ 2-3 times/wk

____ 2-3 times/wk

____ Relaxed

____ Tense

____ Yes

____ No

____ Yes
____ Yes

____ No
____ No

____ 2-3 times/mo or less ____ Never

____ 2-3 times/mo or less ____ Never

Major source of protein you consume:____________________________________________________________

5)

Vegetables:

____ More than 5 servings/day

____ Less than 2 servings/day

Other: ____________

Fruit:

____ More than 5 servings/day

____ Less than 2 servings/day

Other: ____________

If possible, estimate the percentage in your diet of the following types of foods:
Protein ____% Carbohydrates ____% Fat ____%

6)

If you experience any of the following, indicate intensity:

Mild Moderate Severe
Mild Moderate Severe
Bloating after eating?
____
____
____
Heartburn?
____
____
____
Flatulence? (gas)
____
____
____
Nausea after eating?
____
____
____
Constipation?
____
____
____
Fluid retention?
____
____
____
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IV.

Exercise Habits

1) How many times do you exercise (for more than 30 minutes)?

____ 5-7 days/wk

____ 2-4 days/wk

____ 4-8 days/mo

____ Rarely

____ Never

2) How long do you exercise each time? ____________________________________________________

3) Place a 1 next to the type of exercise you do most frequently. Place a 2 next to the second most frequent, etc.
____ Weight Training ____ Jogging/running ____ Walking ____ Aerobics ____ Cycling

____ Swimming

FITNESS GOALS: ________________________________________________________________________________

_______________________________________________________________________________________________
4) When exercising, is it difficult to get into the workout and maintain energy levels?

____ Yes

____ No

5) When working with weights, is it difficult to achieve and maintain a good pump in the muscle?

____ Yes

____ No

6) Are strength levels:

____ Improving

____ Staying the same

7) Do you have any joint or connective tissue problems? (Pain, inflammation, grinding, swelling)

____ Decreasing
____ Yes

____ No

V.

Dietary Recall

Please indicate (and be honest!) all the food and drink you have consumed (in approximate amounts for 3 days)

Day 1: Upon Rising

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Day 2: Upon Rising

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Day 3: Upon Rising

Breakfast

Snack

Lunch

Snack

Dinner

Snack

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We offer solutions and a new approach to building entirely new futures from nutritional /dietary /survival
/financial realities. We have developed a new paradigm of well-being support technologies and products and a
distribution /marketing system that will have a long-term impact in a system in which we must all work together.

We invite you to discuss with us any questions regarding your goals. The best results are based on a friendly, mutual
understanding between our association coaches and member.
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and
understand it is my responsibility to inform this office of any changes in my medical status.

Signature _______________________________________________________ Date ___________________

Additional Notes: ___________________________________________________________________________________________

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