Certified Health Nut Health Assessment

Take a few minutes to complete the assessment below. Your answers will help me and my team better understand where you are today, what you want to improve, and where you want to go. This assessment is designed to help you become more aware of your current heal, lifestyle and goals before your call with my team.

First Name *

Last Name *

Phone *

Email *

Age *

Occupation: *

Height *

Weight *

What would be a win for our time together today? *

What do you want more of in your life? *

What is your big dream? *

Where do you source your water? *

Where do you source your food? *

Typically what time do you go to bed and wake up? *

Do you wake up rested? *

Yes

What type of exercise do you do and how often? *

Do you primarily breathe through your nose or your mouth? *

Nose

Mouth

Both

Not Sure

Do you spend more time in gratitude or worry? *

Gratitude

Worry

Both

Not sure

How much time do you spend in the sun each day? *

What are the 3 most stressful events of your life? *

Do you practice grounding? (Bare feet on the ground) *

Daily

Weekly

Rarely

Never

Whose love did you seek more growing up? *

Mother

Father

Both

Neither

How are your relationships with your family today? *

Great

Not so good

Indifferent

How many alcoholic beverages do you consume each week? *

1-3

4-7

How much caffeine or coffee do you consume each day?

1 - 2

3 - 5

What time do you stop consuming caffeine? *

Have you received COVID Vaccines/boosters? If so how many? *

Approximately how many rounds of antibiotics have you taken in your lifetime? *

Do you take medical drugs now? Which ones? *

Have ever had surgery? (Please explain) *

Do you currently have pain in your body? If yes, where? *

If nothing changes in your life, health, or habits, where do you see yourself five years from now? *

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