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Health History Form

Health History

Consultation Form

Name:

Age

Date of Birth

Address

Phone:

Email:

Occupation

How were you introduced to Don's program?

Lifestyle Goals (Check all that apply)

Feel More Vibrant

Get Better Sleep

Enhance Immunity

Transform Mindset

Increase Mental Clarity

Have More Energy

Gain Muscle

Lose Weight

Increase Confidence

Free Text

Do you smoke?

Yes

No

Do you drink alcohol?

Yes

No

Free Text

Sleep schedule (List normal bedtime and amount of hours)

Describe your job

Rate your stress level (1 being MINIMAL, 10 being EXCESSIVE)

1

2

3

4

5

6

7

8

9

10

Please share with me any health conditions you are currently experiencing:

Do you regularly utilize the services of a massage therapist?

Yes

No

Is anyone in your family overweight?

Yes

No

Were you overweight as a child?

Yes

No

If "Yes", at what age?

When was your last blood test?

On your last blood test, was your fasting blood glucose above 100%?

Yes

No

Unsure

Do you have elevated LDL cholesterol levels?

Yes

No

Unsure

Do you have elevated triglceride levels?

Yes

No

Unsure

What is your current height?

What is your current weight?

What is your typical blood pressure reading?

Low

Average

High

When do you feel you were in the best shape of your life?

Have you been exercising consistently for the past 3 months?

Yes

No

When did you first start thinking about getting in better shape?

What, if anything, stopped you in the past from being in optimal health / physical fitness?

On a scale of 1-10 (1 being WORST, 10 being BEST) how would you rate your current fitness level?

1

2

3

4

5

6

7

8

9

10

How often do you take part in physical exercise?

For how long have you been consistently physically active?

What activities are you presently involved in? (Note Frequency & Duration)

Is cardio conditioning an area that you would like help with?

Yes

No

What types of cardio conditioning are you currently doing , if any? (Note Frequency & Duration)

Is strength training an area that you would like help with?

Yes

No

How would you describe your current diet?

How often do you typically eat per day? (Note the # of meals including snacks)

Do you take supplements?

Yes

No

If currently on a nutritional regimen, please list supplements you're currently taking.

Do you have any food allergies?

Yes

No

If "Yes", please list them.

What time is your first meal of the day?

What is the last time you eat something each day?

What do you crave the most?

If you could prioritize and improve up to 3 things about your health, what would they be?

Thank you for submitting your answers to the Health History Consultation Form. After review, Don will contact you with next steps on your journey to a healthier you.

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- LISA MARTIN
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- THE GRYNDLYFE SHOW

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New Hope, PA

USA

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