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Health Assessment

Personal Information

Full Name

Address

Phone

Email

Birthday

Month

Day

Year

Gender

Male

Female

Marital Status

Single

Married

Widowed

Divorced

Occupation

What shift do you work?

Days

Afternoons

Nights

Are you exposed to chemicals in your occupation?

How did you hear about Renewed Vitality?

Present Complaints

What are your main symptoms?

What are the three things your health issues have caused you to miss the most?

Due to these issues, have you lost time from any of the following? (If so, describe how much time and what tasks have been limited)

Work?

Family

Leisure Activities?

Health History

Current Height:

Current Weight:

Do you have any chronic health conditions? (e.g., diabetes, hypertension, autoimmune disorders) If yes, please specify:

Have you had any surgeries or major medical procedures? If yes, please specify:

Are you currently taking any medications or supplements? Please list:

Do you have any known allergies to medications or drugs? If yes, please specify:

Do you have any food allergies? If yes, please specify:

Do any foods bother you? If yes, please specify:

Do you have any environmental allergies? If yes, please specify:

List any medications you are currently taking:

List any supplements and vitamins you are currently taking:

Have you ever been exposed to toxic mold?

Yes

No

Lifestyle Habits

How would you describe your diet? (e.g., balanced, vegetarian, vegan, keto, etc.)

How often do you exercise? Type of exercise: Frequency per week:

How many hours of sleep do you get on average each night?

Do you smoke or use any tobacco products? If yes, how often?

Do you consume alcohol? If yes, how often?

Do you use any recreational drugs? If yes, how often?

Describe your sleep patterns: (e.g., hours of sleep, bedtime and wake up time, habits, routine, etc.)

Do you exercise? If so, how often and what type of exercise?

Stress and Mental Health

What are your primary health goals? (e.g., weight loss, increased energy, better sleep, managing a health condition)

What motivated you to seek help now?

Have you tried any methods or treatments before to achieve these goals? If yes, what worked and what didn’t?

How committed are you to making lifestyle changes? (1-10 scale)

Rate your stress level on a scale of 1-10 during the average week:

Additional Information

Is there anything else you would like to share about your health or lifestyle that we haven’t covered?

What is your preferred method of communication? (e.g., phone, email, text)

Consent

Do you consent to sharing this information with me for the purposes of a health assessment and guidance?

Yes

No

Signature

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Print Full Name

Date

Month

Day

Year

Renewed Vitality

209-603-2468

amyelizabeth@renewedvitalityca.com

Contact me with any questions! I'd love to help you get started on your journey to enlightenment.

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