Health Evaluation

Name

Email Address

Preferred Phone Number

Gender Identification

Age

Height Heightunder 5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"over 6' 4"

Weight Weight under 120 120 - 140 140 - 160 160 - 180 180 - 200 200 - 220 220 - 240 240 - 260 over 260

Injuries, Diseases, Surgeries

Last Physical and Blood Test

Medications and Supplements

How many times per week do you currently workout? How many times per week do you currently workout? None 1-2 3-4 more than 5

What kind of workouts do you enjoy? What kind of workouts do you enjoy? Jogging/Running Swimming Biking Weights and Strength Training Classes (OTF, Soul Cycle, etc.) Yoga/Pilates Other

Do you visit the Chiropractor? If so, how often? Do you visit the Chiropractor? If so, how often? I do not visit the chiropractor Only when I'm in pain Once every few months Once a month Once a week More than once a week

Do you get massages? If so, how often? Do you get massages? If so, how often? I do not visit the chiropractor Only when I'm in pain Once every few months Once a month Once a week More than once a week

How many hours of sleep do you get per night? How many hours of sleep do you get per night? 1-2 3-4 5-7 more than 7

How many cups of water do you drink per day? How many cups of water do you drink per day? 1-2 3-4 5-7 more than 7

How many alcoholic drinks do you consume on average per week? How many alcoholic drinks do you consume on average per week? 1-2 3-4 5-7 more than 7

Rate your overall nutrition and healthy eating on a scale of 1-10. 1 being very poor, 10 being excellent.

Rate your overall stress level on a scale of 1-10. 1 being very poor, 10 being excellent.

Rate your overall happiness level on a scale of 1-10. 1 being very poor, 10 being excellent.

Rate your overall energy level on a scale of 1-10. 1 being very poor, 10 being excellent.

Any aches, pain, swelling, body issues, including muscles, bones and joints

On average how often do you travel per month?

Do you have a good support system? (Family, friends, counseling, etc.)

What do you want to accomplish with Health and Home? List multiple goals if needed.