Comprehensive Personal Health Assessment
Fill this out the best you can. We can speak in more detail later.
Thank you so much!
-Chris
Name and Phone/Email
Your answer
What is your health goal(s)? *
Required
Why is that your goal(s)? *
Your answer
How will you feel/look when you get there?
Your answer
What else have you tried?
Your answer
On a scale of 1-10, how committed are you to these goals?
Not at all committed..
I will do whatever it takes!
How do you feel now? *
Your answer
What obstacles do you foresee? *
Your answer
Do you have support? An accountability partner or two? *
Your answer
What motivates or inspires you? *
Your answer
What are eating now for breakfast? *
Your answer
How many times a week are you "eating out"? *
Do you drink coffee? How do you take it? *
Your answer
Do you drink alcohol? How often? *
Your answer
Are you on any medications? *
Your answer
How many times a week do you move your body? *
Do you drink enough water? *
How many hours of sleep are you getting? *
On a scale from 1-5, how bad is your stress?
Low and managed
I want to scream almost daily
How often do you want to hear from me?
Do I have your permission to set you up for SUCCESS? *
Submit
Never submit passwords through Google Forms.
This form was created inside of Chris Belin. Report Abuse