Jennifer Leach

Purpose Driven Health, LLC

I'm Soooooo Excited to Connect with You

Hey! I'm so excited to talk with you about your health goals!

1) Please fill out this quick health assessment and then schedule a time that's convenient for you to talk

2) If you feel more comfortable, just schedule a time and we'll walk through it together on the phone.

Talk to you soon!

Health Assessment

First Name *

Last Name *

Email *

Address *

Postal code *

City *

State *

Phone *

Birth Date

AWAKEN... Discover where you are and where you want to be!

Describe where you would like to be in your health...

Describe where you are in your Health now... (weight, sleep, stress, energy, etc)

Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)

When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)? *

How did you hear about our program?

MEDICAL

If Female, Are You Nursing?

Yes

Sex

Male

Female

If yes, how old is your baby?

Do you have any the following?

Diabetes - Type 1

Diabetes - Type 2

High Blood Pressure

Gout

Are there any food or other allergies that I should be aware of?

Are you taking other medications or have other medical conditions that could influence which program we choose?

*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor.

***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.

**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.

SLEEP

What time do you typically go to sleep?

What time do you typically wake up?

How many hours of sleep do you typically get?

How is your quality of sleep?

Do you wake up feeling rested?

HYDRATION

How much water do you drink each day?

How much Soda?

How much Tea?

How much Coffee?

How much Alcohol?

MOTION

How would you rate your energy level? (on a scale of 1-10)

How many times a week do you exercise?

What physical activities do you participate in?

Are there things you can't do that you would like to be able to?

STRESS

What do you do for work?

How would you rate your stress level? (on a scale of 1-10)

How much do you enjoy what you do?

Are there other stressors in your life?

EATING HABITS

How many meals per day do you eat?

When do you eat your first meal?

When do you eat your last meal?

Do you snack between meals?

What kind of snacks?

The average American spends $15-25/day on food. How much do you spend?

Where?

How many times a week do you eat out?

WEIGHT

Current Weight

Height

Goal Weight

On a scale of 1-10 (10 meaning ready to go!), how motivated are you to start working on your health goals?

What has been most difficult about losing/maintaining weight in the past?

SURROUNDINGS

How healthy would you rate your surroundings? (on a scale of 1-10)

Do you have healthy & active friends, supportive family, keep junk food in the house, etc?

Is there anyone in your life who would like to get healthy with you?

Their First Name

Their Last Name