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HEALTH EVALUATION FORM
General Information
Hey! What's Your Name?
What Is Your Best Email?
What's Your Phone Number?
What's The Best Time To Reach You?
02:30 PM
What Is Your Sex?
How Tall Are You?
How Much Do You Weigh?
How Old Are You?
Where Are You Located?
Basic Health Information
How Many Liters Of Water Do You Drink Daily?
What Type Of Water Do You Drink Most Often?
How Much Sleep Do You Get Per Night?
Do You Get Quality Sleep?
What Is The Biggest Stress In Your Life?
Write A Detailed Summary Of Your Diet On An Average Day
List Any Medication/Drugs You Have Taken In The Past 5 Years
On A Scale Of 1-5, How Stressed Out Are You?
List Any Supplements You Have Taken In The Past 12 Months
Health History
Discribe All Of Your Health Problems And Concerns
How Long Have You Been Trying To Fix These Health Problems?
What Have You Tried/Trying Already To Fix These Health Problems?
What Do You Believe Is The Biggest Reason Why You Haven't Achieved Your Health Goals Yet?
What Do You Believe Is The Most Important Solution, To Finally Achieve Your Health Goals?
Out Of All Of Your Health Problems Which One Is Your Top Priority To Fix Right Now?
Goals & Achievements
If You Could Get Anything Out Of Working With Us, What Would That Be?
How Much Time Do You Currently Spend Working Toward Your Goals?
How Much Time Do You Could You Be Spending Working Toward Your Goals?
What Is Your Biggest Reason For Wanting To Optimise Your Health?
On A Scale From 1-5, How Important Is Fixing Your Health To You?
Final Questions
Are You Financially Able To Invest In Your Health?
On A Scale From 1-5, How Disciplined Are You?
On A Scale Of 1-5, How Stressed Out Are You?
On A Scale Of 1-5, How Confident Are You In Yourself?
On A Scale Of 1-5, How Confident Are You That We Can Actually Help You?
How Did You Hear About Us?
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