Health Pre-Assessment


Please complete this questionnaire at least 3 days before your appointment. 

Answers are optional, but will assist in understanding your health status. All information given is confidential.



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1. Reasons you to speak with a health coach:

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4. In a typical WEEK, how many times do you eat fast food/take-out?

8.In a typical WEEK, how many servings of the following do you drink (1 serving = 8 oz.)?

Sugar-sweetened beverages (incl. juice)

Beverages with artificial sweeteners:

Alcoholic beverages

Caffeinated beverages

9. List the top 3 things you consider when preparing food:

10. In a typical WEEK, how many days are you physically active?

11.In a typical DAY, how much time do you spend…

Using a cell phone / Watching TV:

Using a computer:

Being physically active (running, playing with kids, organized sports, walking, dancing, weight lifting, biking etc.):

12. In a typical WEEK, how often do you enjoy doing hobbies or something fun with others?

13. How important is your spiritual life?

14. Please rate your current stress level ( 1=low/10=out of control):

Thank you for completing this questionnaire!

Please Click below to submit this form.