Health Lifestyle Assessment Form

Please list your 3 primary goals

Please record a food diary for three typical days of your diet. Please include one weekend day.

Please record a fitness/workout diary for a typical week. Indicate the day of week and the time of day of each workout.

Please indicate if you suffer from any of the following (answers to each question are required)

Low Blood Pressure*: NoYes
High Blood Pressure*: NoYes

Thyroid Condition*: NoYes
Irregular Heartbeat*: NoYes

Heartburn*: NoYes
High Cholesterol*: NoYes

Diabetes*: NoYes
Nausea*: NoYes

Please indicate if you have ever suffered from any of the following

Yeast Infections: NoYes
Lack of Energy: NoYes

Athlete's Foot: NoYes
Muscle Fatigue: NoYes

Jock Itch: NoYes
Nasal Drip: NoYes

Skin Rashes: NoYes
Sinus Problems: NoYes

Eczema: NoYes
Neck Pain: NoYes

Frequent Headaches: NoYes
Back Pain: NoYes

Circulation Problems: NoYes
Inability to Concentrate: NoYes

Joint Cracking: NoYes
Joint Pain: NoYes

Joint Inflammation: NoYes
Brain Fog: NoYes

Poor Memory: NoYes
Mood Swings: NoYes

Depression: NoYes
Insomnia: NoYes

Irritable Bowel: NoYes
Ulcers: NoYes

Colitis: NoYes
Crohn's: NoYes

What level of stress are you experiencing right now?

Financial: NoYes
Career: NoYes

Personal: NoYes
Marriage: NoYes

Health: NoYes
Family: NoYes

Spiritual: NoYes
Unfulfilled Expectations: NoYes

Do you awaken feeling rested? NoYes

Do you smoke? NoYes

Do you drink? NoYes

Do you take prescription drugs? NoYes

Do you currently take any supplements? NoYes

Do you have a personal trainer? NoYes