Health Assessment Form

Name*
First Last
Date
Physician

Age	Height	Weight

What is your primary goal?
What makes it hard for you to lose weight and keep it off?
What is your secondary goal?
What are the biggest barriers that are preventing you from reaching your health goals?
Is there anyone in your life who does NOT want you to make changes to your diet and exercise?
Weight History
Years at present weight Highest weight Year Desired weight Year last at desired weight Longest time desired weight maintained
Weight pattern (check 1)
- Stable
- Yo-Yo
- Slow Gain
Diet Programs / Centers that you have tried.
Diet Products that you have tried.
What has worked in the past to manage your weight and/or medical condition(s)?
Lifestyle - Work/School
Do you attend school?
- Yes
- No
If yes, how many hours per day/week do you attend school?
If you work, your job is mostly (check one):
- Sedentary (mostly sitting)
- Active (mostly on my feet)
- Physically demanding
Please list your occupation
If you work, do you travel for work?
- Yes
- No
If yes, how many nights per month are you gone?
Dietary Habits
Number of daily meals you eat?
What are the normal hours you eat?
Breakfast Lunch Dinner
Number of daily snacks you eat?
When do you eat?
AM snack PM snack Evening snack
Do you skip meals?
- Yes
- No
Are you a fast eater?
- Yes
- No
Do you eat microwave / TV dinners?
- Yes
- No
Do you like to cook?
- Yes
- No
Do you consider yourself a good cook?
- Yes
- No
Most of my meals are (check one):
- Prepared from scratch
- Heat/Cook and eat
- Take out
What is the approximate percentage of where you eat?
%Home %Restaurant %Fast Food %Work/School %In the Car
Are you allergic or intolerant to any foods?
If so, what foods?
How much of each beverage do you typically consume each day?
Water Juice Milk (skim, 1 or 2%, whole) Tea Coffee Energy Drinks Soda Diet Soda Sports Drinks Other
If you drink alcohol, how many drinks (on average) do you have per week?
What factors, other than hunger, lead to eating for you (tick all that apply)
- Boredom
- Social Situations
- Depression
- Emotional Upset
- Anger
- Happiness
- Loneliness
- Nervousness
- Seeing food
- Stress
- Time of Day
- Fatigue
- Other
How often do you eat emotionally?
How often do you eat late at night (select one):
- Never
- Occasionally
- Often
What do you typically eat for emotional reasons or late at night?
What are you likely to be doing while you’re eating (select all that apply)?
- Watching TV
- Reading
- Driving
- Other
Do you ever make yourself throw up after eating?
- Yes
- No
If so, how often?
Do you binge eat (i.e., eat large amounts of food while feeling out of control)?
- Yes
- No
If so, how often?
What triggers binges?
On a scale of 1 – 10 (with 1=starving and 10=stuffed), what number are you usually at before eating a meal or snack?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
What number are you at after eating a meal?
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Have you ever used meal replacement drinks or nutrition bars?
- Yes
- No
Miscellaneous
Is spirituality a part of your lifestyle?
- Yes
- No
If so, do you feel comfortable discussing these aspects with me?
- Yes
- No
- Maybe
Health History
Do you have any medical conditions and/or diagnosis?
- Yes
- No
If so, what are they?
- High Blood Pleasure
- Diabetes
- Anemia
- High cholesterol
- Acid reflux
- Pregnancy
- Other
What medications do you take?
Do you take vitamins?
- Yes
- No
If so, what are they?
Do you take supplements / herbs?
- Yes
- No
If so, what are they?
What is your cholesterol level?
Your usual blood pressure?
Please list any digestive problems you have and/or concerned about (i.e. constipation, frequent stomach aches, diarrhea, cramping, etc.)
How many hours, on average, do you sleep per night?
What is your sleep pattern (select one)?
- Sleep through the night
- Often wake up and can’t go back to sleep
- Often have trouble falling asleep
On a scale of 1-10, how do you rate your stress level (1=lowest, 10=highest):
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
How do you cope with stress?
Please list any skin problems you are concerned about.
What is your body composition?
Date Taken?
Type of analysis?
Where taken?
Goal?
Do you smoke?
- Yes
- No
If yes, how many cigarettes per day?
Please list any religious practices that affect your heath care or diet:
Women only.
Menstrual status (select one):
- Normal periods
- Sporadic
- None
ACTIVITY ASSESSMENT
Have you worked with a personal trainer / fitness professional in the past?
- Yes
- No
Are you interested in working with a personal trainer more than once per week?
- Yes
- No
If yes, how many days per week?
If you work out, when do you usually (select all that apply)?
- Morning
- Afternoon
- Evening
- During the week
- Weekends
Are you currently or have you ever visited with a counselor, therapist, or psychologist about food, eating, or body image issues? If so, when and for how long? Are you interested in talking to one about any concern you have regarding your relationship with food, your relationship with people in your life, stress management, anxiety, or body image.