Health Assessment Form — Hamptons Wellness

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HEALTH ASSESSTMENT FORM

For a first assesment of your needs, please let us know about your health history. Each person is unique and program customization is our priority.

Name

First Name

Last Name

Phone

(###)

###

####

Age

Height

Birthday

YYYY

Current Weight

Weight six months ago

Weight one year ago

Would you like your weight to be different? If so, what?

Relationship status

Children

Pets

Occupation

Hours of work per day

Hour

Minute

Second

Please list your main health concerns

Other concerns or goals?

At what point in your life did you feel best?

Any serious illnesses/hospitalizations/injuries?

How is/was the health of your mother?

How is/was the health of your father?

What is your ancestry?

How is your sleep? How many hours?

Any pain, stiffness, or swelling?

Constipation/Diarrhea/Gas?

Allergies or sensitivities? Please explain

Do you take any supplements of medication? Please list

What role does sports and exercise play in your life?

What foods did you eat often as a child?

What is your food like these days?

Will family/friends be supportive of your desire to make food/lifestyle changes?

Do you cook? How often and what do you get the rest from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I should change about my diet to improve my health is:

Anything else you would like to share?

HEALTH ASSESSTMENT FORM

Elizabeth Cassone

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