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Congratulations for Choosing You!

Take our complimentary Nutrition and Health Assessment Form and Email to ilysha@chooseyou365.com. After Receiving Your Assessment We Will Schedule a 30 min Call to Review Your Results.

Health Evaulation Form

Date:

Name:

Gender:

Age:

Email:

Height:

Weight:

Ideal Weight:

Body Fat % (if known):

Ideal Body Fat %:

Waist Circumference:

Ideal Waist Circumference:

In what part/s of your body do you feel you carry the majority of your weight? And is this where you have always held weight or is this a new problem area?

Medical/Health Issues:

Injuries/Limitations/Past Surgeries (include dates of surgeries):

Current Medications (prescription and over the counter):

Current Supplements (please include Brand and dosage):

Personal Goals (Describe what you would like to accomplish in the next 90 days together – if you have more short-term or long-term goals, list these as well)

Previous nutrition and fitness programs and their outcomes:

Occupation:

How many hours do you work/week? Is shift work involved?

How often do you travel with your job?

Exercise:

Cardio (type/amount of time per week):

Strength (type/amount of time per week):

Other:

Food Log from YESTERDAY (include the time of your meal AND the portions – the more detailed the better!):

Breakfast:

Snack:

Lunch:

Snack:

Dinner:

Snack:

Hydration/Beverages:

Water intake (oz per day):

Caffeine intake (oz per day & type consumed):

Alcohol intake (# drinks per week & type consumed):

Any other liquids (amount & type consumed)

Average Stress level (0 – 10 with 10 = overwhelmed/overcommitted) =

What are your stressor/s:

Sleep: Bed at what time –

Awaken at what time –

Quality – discuss any issues with falling asleep and/or staying asleep:

Please highlight any statements below that best represent you and what you are experiencing/struggling with currently (feel free to add in any additional comments you believe are pertinent):

Inflammation

· Do you take longer to recover from exercise, ie. extended soreness?

· Do you have joint or muscle aches regularly?

· Do you eat less than 2 servings of non-starchy vegetables per day?

· Is your diet high in sugar and/or trans fats?

· Do the majority of your meals come from fast food restaurants and/or pre-packaged meals?

Digestive Health

· Do you often get bloated and gassy, especially after eating?

· Do you have trouble with constipation (< 1 bowel movement a day)?

· Do you have trouble with diarrhea and/or loose stools?

· Do you often feel mentally foggy or have trouble concentrating?

· Do you have eczema, rosacea, acne, or any other skin condition?

· Do you have seasonal or food allergies/sensitivities?

o If yes, please list:

· Do you suffer from acid reflux and/or heartburn or take prescription or over the counter antacids?

Immunity and Nutrient Deficiencies

· Are you usually tired?

· Are you susceptible to colds and flus or do you get sick often?

· Do you take oral contraceptives, acid blocking drugs, or steroid-related meds?

· Do you have tight muscles that do not loosen up easily?

· Do you get muscle cramps regularly?

Stress and Sleep

· Are you under high stress from personal or work-related stress or from being overcommitted in your life?

· Do you crave sugars or carbohydrates in the afternoon and evening?

· Do you have trouble falling asleep or staying asleep?

· Do you often have a mid-day crash in energy?

· Do you feel anxious or nervous?

· Do you sleep less than 7 hours per night?

· Do you get dizzy or lightheaded when standing?

· Do you take in more than 4-6 cups of coffee per day for energy?

Women’s Sex Hormones

· Are your menstrual cycles irregular, are you periods heavier than usual periods, and/or do you have excess cramping)?

· Are you menopausal?

· Are you experiencing hot flashes or night sweats?

· Do you have mood swings, irritability, depression, or breast tenderness with your cycle?

· Do you have fluid retention and weight gain during your cycle?

· Do you have endometriosis, fibrocystic breasts, or hot flashes?

· Have you been diagnosed with Polycystic Ovarian syndrome?

Men’s Sex Hormones

· Do you have trouble maintaining lean muscle or gaining muscle mass?

· Do you notice a loss of interest in activities you enjoyed?

· Do you seem more prone to injuries and/or have a harder time recovering from injuries?

Environmental Toxins

· Do you have extreme difficulty losing more than ten pounds?

· Do you have chronic unexplained headaches, muscle pain, and/or fatigue?

· Do you have allergies or asthma?

· Do you have chemical sensitivities such as intolerance to fragrances/odors?

· Do you regularly have bad breath, sour taste in your mouth, or excessive body odor?

Glucose Balance

· Are you irritable if you miss a meal, or jittery/anxious if you go more than 4 hours without food?

· Are you >20# over your ideal body weight with the majority of weight gain around the midsection?

· Do you have sporadic energy boosts and drops throughout the day?

· Do you crave carbohydrates (bread, potatoes, or pasta) or sweets excessively?

· Have you been diagnosed with diabetes, insulin resistance, or metabolic syndrome?

Thyroid and Metabolism

· Do you feel tired from morning to night?

· Do you have dry skin, cracked nails, or brittle hair?

· Do you have thin hair or lose excess hair with brushing?

· Do you have cold hands and feet?

· Do you have extreme difficulty losing weight?

· Have you been diagnosed with hypo/hyperthyroidism or are you currently taking thyroid medication?