Health & Fitness Assessment Fitness and Health Assessment How is your self-image? Check one: Good Fair Indifferent Bad How is your self-image? Check one: Are you satisfied with your self image? Yes No What are your current and target weight goals? How many hours do you sleep (average)? How many times/week do you exercise? Rate your Fitness on a Scale of 1 – 10: Cardio-vascular: 12345678910 Strength 12345678910 Flexibility: 12345678910 Balance: 12345678910 Do you have any concerns or restrictions regarding exercise? Are any health issues being addressed by your medical professionals? Are you current with screenings and physicals? Do you make healthy food choices most of the time? What is your level of stress? High Medium Low None How happy are you? Do you have a sense of purpose? Do you feel appreciated? Do you have satisfying relationships? How would you like to see yourself in 1 year? Do you set goals for yourself? What supplements do you take? Please list Do you have one or more trusted medical professionals you consult when necessary? Current opinion is health is 20% genetics and 80% lifestyle. Do you feel your lifestyle will contribute to your longevity? Yes No Maybe Is there anything you would like to add to provide more information? Would you like to be included on my mailing list to be notified of events and new programs, information about protocols and products that promote optimal health and longevity? I promise you won’t be barraged with emails.. 🙂 Yes No Please include your email here: If you are human, leave this field blank. Submit
