Health Assessment Form Name* First Last Date PhysicianAgeHeightWeight 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 HistoryYears at present weightHighest weightYearDesired weightYear last at desired weightLongest 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/SchoolDo 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 occupationIf you work, do you travel for work? Yes No If yes, how many nights per month are you gone?Dietary HabitsNumber of daily meals you eat?What are the normal hours you eat?BreakfastLunchDinner Number of daily snacks you eat?When do you eat?AM snackPM snackEvening 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?YesNoIf so, what foods?How much of each beverage do you typically consume each day?WaterJuiceMilk (skim, 1 or 2%, whole)TeaCoffeeEnergy DrinksSodaDiet SodaSports DrinksOther 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?12345678910 What number are you at after eating a meal?12345678910Have you ever used meal replacement drinks or nutrition bars? Yes No MiscellaneousIs 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):12345678910How 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 ASSESSMENTHave 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.