21-Day Summer Shred Fill out the Health History Survey below and receive a free Evaluation and Consultation Start Health History Survey Free Consult/Eval Survey Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY How did you hear about us? Facebook Instagram Tiktok Referal Lifetime Other Do you have any medical conditions? * How much sleep do you get per night * What are your physical limitations * What type of exercises do you like to do? What is your daily nutrition like? * Are you currently experiencing any of the following? Pregnant Breast Feeding Active Cancer Cholecystitis Dialysis None of the above Check all that apply to you: Do you currently experience any of the following conditions even if they are minor and go away on their own? Gallbladder Issues Digestive Problems Diabetes Stress Irregular Bowels/Constipation Neck Pain Chronic Inflammation Hip/Knee Pain Gas/Bloating/Belching Numbness / Tingling Thyroid Problems Consume alcohol Headaches Chronic Fatigue Allerigies Upper Back Pain Osteoporosis Rate any constipation you are have experienced in the last year: 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any abdominal pain or bloating you have experineced in the last year * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any mucous or blood in stool in the past year * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any joint pain or swelling, arthritis in the past year * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any chronic fatigue or tiredness over the past year * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any food allergies, sensitivities, or intolerances * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any sinus or nasal congestion * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any chronic or frequent inflammations * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any eczema, skin rashes, any/or hives * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any asthma, hay fever or airbourne allergies * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any confusion, poor memory, mood swings * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any use of NSAIDS (Asprin, Tyenol, and/or Motrin) * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any history of antibiotic use * 0 = Never 1 = Mild 2 = Moderate 3 = Severe How frequently does alcohol consumption make you feel sick? * 0 = Never 1 = Sometimes 2 = Mostly 3 = Always Rate any ulcerative colitis or Celiac's disease * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate any nausea * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Rate weight trouble * 0 = Never 1 = Mild 2 = Moderate 3 = Severe Are you currently on any medications and for what health condition? Do you currently take nutritional supplements? if yes, which ones? Why do you currently want to lose weight? List any specific health goals you would like to achieve: How long have you struggled with your weight? How much weight do you want to lose? Have you tried other wight loss plans and if so, what have you tried? What were the results? Why do you think they didn't work? Are you ready for a different approach? How does your commitment differ from previous times in your past? What does the excess weight prevent you from doing? What is it costing you? What is the biggest challenge right now in your weight loss journy? What is your support system look like? How would you describe your health journy up until now? Do you have any other health challenges that you feel is important for us to know about? Thank you!
