Evaluation

    Personal Information

    Name (required)

    Address

    City

    State

    Best Phone #

    Alternate Phone #

    Your Email (required)

    Birthdate

    Physical Information

    Height
    ft in

    Current Weight
    (lbs)

    Max Weight
    (lbs)

    Max Weight Year
    (YYYY)

    Health Concerns

    What are your most important health concerns?

    Describe anything that may have contributed to these concerns

    Goals

    What are your Goals?

    Medical

    Please describe all hospitalizations and surgeries

    Please list all current medications and suppliments

    Risks

    Do you smoke?

    Quantity per day

    For how many years

    Exercise

    Do you current exercise?

    If so, describe (type, duration, frequency)

    Sleep

    How many hours of sleep to you get per night?

    Do you fall asleep easily?

    Do you wake often during the night?

    Do you wake up feeling rested?

    Medical History

    Indicate if you or a family member has had any of the the follow (now or in the past)

    Disease Self Family
    Alcoholism Self Family
    Anemia Self Family
    Anorexia Self Family
    Arthritis Self Family
    Asthma Self Family
    Binge Eating Self Family
    Bulimia Self Family
    Cancer Self Family
    Compulsive overeating Self Family
    Crohn's disease/colitis Self Family
    Depression Self Family
    Diabetes Self Family
    Food Allergies or Sensitivities Self Family
    Heart Disease Self Family
    Hepatitis Self Family
    Herpes Self Family
    High Blood Pressure Self Family
    Low Blood Pressure Self Family
    High Cholesterol Self Family
    HIV Self Family
    Hypoglycemia Self Family
    Irritable bowel syndrome Self Family
    Kidney disease Self Family
    Lupus Self Family
    Lyme disease Self Family
    Mental illness Self Family
    Migraine Headaches Self Family
    Multiple Sclerosis Self Family
    Stomach/Intestinal Ulcers Self Family
    Stroke Self Family
    Substance Abuse Self Family
    Thyroid disease Self Family