Health Assessment Please take a few minutes to fill out this confidential Health Assessment, and I will contact you ASAP. Thanks so much. FrancisName Age Date Email Address (Street, City, State, Zip Code) Cell # Please describe where you are in your health now? Describe where you would like to be in your health? Describe why you would like to get healthy? When was the last time you remember feeling good about your health? Please list any doctor diagnosed medical conditions you presently have? Please list any medications you are presently on? How many hours sleep do you typically get a night, and what is the quality of your sleep? What time do you get up, and what time do you go to bed? How many ounces of water do you drink a day? ( A bottle of water is 16.9 oz.) What other beverages do you drink, and how much? What physical activities do you participate in? How often? What do you do for work? How many meals a day do you eat, and when? What do you typically eat for these meals? What kind of snacks do you eat in-between meals? What is your current weight? Goal weight? Height? Thank your for taking the time to fill this out! Δ
