Name *
Name
Cell Phone
Cell Phone
Address
Address
Date of Birth
Date of Birth
Do you have children?
Are you pregnant?
Date of last physical exam
Date of last physical exam
GOALS AND READINESS ASSESSMENT
On a scale of 1 (not willing) to 5 (very willing), please indicate your willingness to do the following
Significantly modify your diet
Take nutritional supplements daily
Keep a record of everything you eat
Modify your lifestyle (ex: work demands, sleep habits, exercise)
Engage in regular physical activity or exercise
Have periodic lab tests to assess progress
LIFESTYLE ASSESSMENT
Activity
Type/Intensity
Number of Days/Week
Duration (Minutes)
Type/Intensity
Number of Days/Week
Duration (Minutes)
Type/Intensity
Number of Days/Week
Duration (Minutes)
Type/Intensity
Number of Days/Week
Duration (Minutes)
Type/Intensity
Number of Days/Week
Duration (Minutes)
Indicate daily stressors and rate level of stress from 1 (extremely low) to 10 (extremely high):
On average, how many hours of sleep do you get?