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?
    MinimalAverageConsiderableUnbearable

    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