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Health Form Evaluation
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Email
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Personal
First and Last Name:
Your answer
Age:
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Height:
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Date of Birth:
MM
/
DD
/
YYYY
Place of Birth:
Your answer
Email:
Your answer
Mobile Number:
Your answer
Current Weight:
Your answer
Weight 6 Months Ago:
Your answer
Weight 1 Year Ago:
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Would you like your weight to be different?
Yes
No
Clear selection
If so, why?
Your answer
Why did you sign up for a Health Evaluation?
Your answer
What is your relationship status?
Single
Married
Dating
Complicated
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Do you have any pets?
Yes
No
Clear selection
Do you have a large or small groups of friends?
Large group of friends
Small groups of friends
Clear selection
What do you do for fun?
Your answer
General Health
What are your main health concerns?
Your answer
What are some of your Goals?
Your answer
At what point inf your life did you feel your best?
Your answer
Any current or previous serious illnesses, hospitalizations or injuries?
Your answer
Health History
What is your Ancestry?
Your answer
How is/was your mother's health?
Your answer
How is/was your father's health?
Your answer
Health
How is your Sleep?
Your answer
How many hours do you sleep per night?
4-6 hours
7-9 hours
10+ hours
Clear selection
Do you wake up during the night? If so, why?
Your answer
Any pain, stiffness, or swelling?
Your answer
Any constipation, diarrhea, or gas?
Your answer
How frequent are your Bowel Movements? (Daily, Weekly?):
1-2x a day
3+ a day
1-2x a week
3-5x a week
7+ a week
Other:
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Do you get Stomachaches?
Yes
No
Other:
Clear selection
Do you get headaches or earaches?
Your answer
Any allergies or sensitivies?
Your answer
Menstrual
Are your periods regular?
Yes
No
Other:
Clear selection
How many days is your flow?
Your answer
How Frequent?
Your answer
Are your periods painful or symptomatic? If so, please explain:
Your answer
What is your birth control history?
Your answer
Do you experience yeast infections or urinary tract infections? If so, please explain:
Your answer
Medical
Are you concerned with your body image? If so, please explain:
Your answer
Do you take any supplements or medications?
Your answer
Are you involved with any healers, helpers, or therapies?
Your answer
Exercise
What role does exercise play in your life?
Your answer
What are your favorite activities outside of exercise?
Your answer
What are fun things you do with your family/friends?
Your answer
What are your favorite things to do when you are alone?
Your answer
Food
Will your family & friends be supportive of your desire to make lifestyle changes?
Yes
No
Maybe
Other:
Clear selection
What percentage of your food is home-cooked?
Your answer
Do you enjoy the food?
Yes
No
Sometimes
Other:
Clear selection
Where does your non-home-cooked food come from?
Your answer
Do you crave sugar, coffee or smoking?
Sugar
Coffee
Smoking
None
Other:
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Do you have any other addictions (ex: social media or tv)?
Your answer
What foods do you wish you could eat more often?
Your answer
What foods do you wish you never had to eat again?
Your answer
What do you want to learn about your body & food?
Your answer
Food History
What food did you eat often as a child? (List for Breakfast, Lunch, Dinner, and Snack)
Your answer
What food do you typically eat now? (List for Breakfast, Lunch, Dinner, and Snack)
Your answer
What is the most important thing you should change about your diet to improve your health?
Your answer
YAY!! You are Done! Add any comments
Please share anything else you would like me to know:
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Now please Schedule your Call time with Coach Ashslay!
https://calendly.com/coachashslay/15min
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