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HEALTH CONNECT

Create the healthiest YOU!

Preferred Method of Contact

Text

Call

Email

Where you are and Where you want to be

MEDICAL

Are you pregnant?

Yes

No

Are you nursing?

Yes

No

If yes, how old is your baby?

Do you have the following?

Diabetes - Type 1

Diabetes - Type 2

High Blood Pressure

Gout

Are you taking any medications for the following?

Diabetes

High Blood Pressure

High Cholesterol

Thyroid*

Lithium**

Coumadin (Warfarin)***

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?

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

SLEEP

How many hours of sleep do you typically get?

What time do you typically go to bed?

How is your quality of sleep?

What time do you typically wake up?

Do you wake up feeling rested?

HYDRATION

How much water do you drink each day?

How much tea?

How much coffee?

How much soda?

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

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

What do you do for work?

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 last meal?

When do you eat your first meal?

Do you eat snacks between meals?

What kind of snacks?

How many times a week do you eat out?

Where do you go when you eat out?

WEIGHT

Current Weight

Height

Goal Weight

Have you tried to lose weight before?

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?

Thanks for submitting, I will be in touch!