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Initial Assessment Form
Please fill this out to the best of your ability. Understanding where you are starting from is EXTREMELY important to us. It is also vital for your own SUCCESS and SAFETY.
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Street Address (Please include City, State, Zip Code)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Health Care Provider Name and Contact Info
*
Your answer
Please list all medications you are currently taking.
*
Your answer
Please list all vitamins/supplements you are currently taking.
*
Your answer
Please list all food allergies or sensitivities.
*
Your answer
Do you have any exercise restrictions?
*
No
Yes
Required
If you answered Yes, please explain below.
Your answer
Short Term Goals: What do you want to have change within 4-6 weeks? (Physical, Nutrition, Mental Wellness, Lifestyle etc.)
Your answer
Long Term Goals: What do you want to have change within the next 6 months- a year? (Physical, Nutrition, Mental Wellness, Lifestyle etc.)
Your answer
Rate your current commitment level.
*
Low
1
2
3
4
5
6
7
8
9
10
High
What is your current baseline stress level?
*
Low Stress
1
2
3
4
5
6
7
8
9
10
High Stress
What are your current sleep habits? Check all that apply.
*
Less than 5 hours/night
Between 5-7 hours/night
7+ hours/night
Hard time falling asleep.
Struggle to stay asleep.
Wake 2+ times/night
Generally feel rested upon waking.
Generally feel groggy/tired upon waking
Other:
Required
How satisfied are you with your current nutrition?
Needs Work
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2
3
4
5
6
7
8
9
10
Satisfied
Clear selection
How many days each week are you exercising?
1-2 Days
2-3 Days
3-4 Days
5-6 Days
6-7 Days
Clear selection
Do you have any initial questions or concerns for us?
Your answer
Thank you!!! We are very excited to be working with you and can’t wait see all the progress you will be making!
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