My Story

Take The First Step Towards Health
Health Assessment Form

Rate yourself for each category using the rating system below to score yourself.
0 to 3: Low energy, feeling overwhelmed, not functioning well, poor food choices.

4 to 7: Feeling/performing OK; some healthy choices, room to improve.
8 to 10: Feeling/performing well, making healthy choices, steady improvement.
Name*
First Last
Email*
Phone*
Vitality Indicator
Stress & Anxiety*
Please enter a number from 1 to 10.
Mental Clarity*
Please enter a number from 1 to 10.
Focus*
Please enter a number from 1 to 10.
Sleep Quality*
Please enter a number from 1 to 10.
Energy Level*
Please enter a number from 1 to 10.
Positive Outlook*
Please enter a number from 1 to 10.
Stamina*
Please enter a number from 1 to 10.
Digestion*
Please enter a number from 1 to 10.
Healthy Eating*
Please enter a number from 1 to 10.
General Feeling of Wellness*
Please enter a number from 1 to 10.
Weight Management*
Please enter a number from 1 to 10.
Caffeine Consumption*
Please enter a number from 1 to 10.
(Based on the number of cups per day - the more you drink the lower your score)
Total*
What would you like to improve most? Please write a short comment below.