This valuable information will provide a reality check of where your daily actions are taking you in terms of your health and well-being. It is an important exercise that will require your full focus, away from noise, interruptions, cell phones and other distractions. Its accuracy will be completely dependent on answering each question as truthfully as possible, basing your response on your most current and consistent behavior - what you are doing now, not last week or last month, or last year.

Before you begin, look at the chart above. It depicts the health continuum, from sick to non-sick, to optimal health and beyond. For reference, most people find themselves somewhere in the unhealthy range of scores, in the non-sick zone between sick and optimal health.
Email address *
What is your First and Last Name? *
What would you like to accomplish with your health? *
Were you referred to this assessment by someone? *
If yes, who referred you? (First and last name, please)
On a scale of 1-10 how would you describe your current state of health?
Clear selection
How much weight would you like to lose?
When were you last at that weight and what changed?
What would it mean to you to be at that healthy weight again? (how would it affect the way you feel, activities, relationships, etc)
What is your main motivation for wanting to make changes to your health?
How many hours do you sleep in a typical night?
How much water do you drink in a day? (think in terms of # of 16 oz. bottles)
On a scale of 1-10 how would you rate your energy level?
Clear selection
What type of physical activity do you engage in and how often?
On a scale of 1-10, how would you rate your stress level?
Clear selection
What do you do for work? Do you enjoy what you do?
How many meals per day do you eat?
What unhealthy patterns in your eating habits would you like to change?
How often do you eat out in a typical week?
How much do you spend on groceries each month?
How old are you?
How tall are you?
How much do you currently weigh?
Have you tried losing weight in the past? If yes what did you do?
Do you have any of the following health considerations?
Is there anything else about your health that would be important to know?
Who else in your life would you want to see get healthy with you?
What is the best number to contact you to go over your results?
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