Life Style Assessment Form

Lifestyle Assessment Form

Congratulations on taking the first step toward a healthier lifestyle! Please take a few moments to complete this questionnaire below. All information is kept confidential.

APersonal Information

First Name

Last Name

Mailing Address

Date of Birth

Age

Gender

Male Female

Height (ft/in or cm)

Weight (lbs or kg)

Daytime Phone

Evening Phone

BMy Lifestyle & Fitness Goals

Healthy weight loss Improve overall health Improve flexibility Healthy weight gain Prevention of disease Address medical conditions Increase physical activity Increase strength Other Make better food choices Increase physical endurance

Target Weight

Target Date for Attaining Weight Goal

CMedical History

Do you currently experience the following symptoms or have been diagnosed with any of these medical conditions? Check all that apply.

Allergies Digestive Health (IBS, Crohn's) Joint Pain Anxiety and Stress Osteoporosis, Osteoarthritis Heart Disease Asthma Low Back Pain High Cholesterol Depression Neck Pain Migraine, Headaches Diabetes Type 1 Chronic Muscle Soreness Other, specify Diabetes Type 2 Injuries

If “Other” — please specify

Are you pregnant?

No Yes

If yes, anticipated due date

Do you currently smoke?

No Yes

If yes, cigarettes/cigars per day & for how long

Have you ever smoked?

No Yes

Does anyone else smoke in your household?

No Yes

Your workplace?

Yes No

Family history / hereditary diseases

Health of relatives (Father / Mother / Siblings)

Have you ever been hospitalized?

No Yes

If yes, what was the reason?

I confirm that the information provided above is accurate to the best of my knowledge, and I consent to Heavenly NHH Virtual collecting this information in accordance with applicable privacy regulations.

We believe that exercise isn’t just about how it makes you look, but also how it makes you feel. Get fit today.

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Contacts

450 NW Couch Street, America, Oregon 89704
+ (123) 1234-567-8990

Every day: 9:00 – 22:00
Sat – Sun: 8:00 – 21:00

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