Health & Wellness Intake FormPlease enable JavaScript in your browser to complete this form.Personal Data - Step 1 of 12If the form below looks strange, please turn your phone so your screen is wide.What's your name? *How can we call you? *Where can we send emails? *What is your address? *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat is your date of birth?MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *Do you have children? *YesNoHow many children do you have? *Education LevelNo High SchoolSome High SchoolHigh SchoolSome Higher EdAssociates DegreeBachelors DegreeMasters DegreeDoctoral DegreeAre you a service member?Yes, currentlyYes, previouslyNoDate of enlistmentMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of dischargeMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What Branch?ArmyNavyAir ForceMarinesCost GuardSpecial ForcesOtherAre you satisfied with your present occupation?YesNoWhat is your current occupation? And where do you work?NextHave you or your family ever received counseling for any reason?YesNoWhen?MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What was it for?Are you currently working with any other health coach or fitness trainer?YesNoIf so, with whom, where, why, and for how long?Briefly describe yourselfList relatives with a history of health issues. Emergency Contact *FirstLastEmergency contact phone numberNextReligious FaithChristianity (Protestant)Christianity (Catholicism)IslamHinduismAgnosticismBuddhismAtheismSikhismSeventh-Day AdventistsLatter Day SaintJudaismProtestant Denomination (if any)BaptistNondenominationalMethodistPentecostalLutheranPresbyterianRestorationistEpiscopalian / AnglicanCongegationalistAdventistAnabaptistOther EvangelicalOther ReformedPietistQuakerUnsurePresent church affiliation or name of church you attendHave you accepted Jesus as your Lord and Savior?YesNo UnsurePlease tell me about that... NextPhysician *Physician phone numberDate last seenReason for last appointmentIs your doctor concerned about any of the following?Blood PressureSmokingCholesterolFamily HistoryWeightBlood Glucose LevelTriglyceride LevelsOtherIf you checked other above, please explain.Ongoing medical concernsCurrent health challengesAllergiesCurrent medicationsHeightCurrent WeightDesired WeightHave you had any major injuries, surgeries, or ongoing health conditions that will affect your long-term health and wellness?YesNoIf yes, please describe in further detail.NextAre you happy with your diet right now?YesNoWhy or why not?What would you like to change?How often do you eat per day? How often do you eat fast food? At a restaurant?Where do you typically eat out?How often do you eat homemade meals (even for lunch)?Who does the grocery shopping in your home? And where do you/they shop?Describe a typical breakfast.Describe a typical lunch.Describe a typical dinner.What do you eat for snacks?On average, how many servings of fruits do you eat per day? How many servings of vegetables?What are your primary sources of protein?Click any substances that you use.AlcoholTobaccoOtherHow often do you use these substances?NextCheck any activities you are currently participating in:WalkingYogaPilatesIndividual SportsTeam SportsRunningGroup FitnessCyclingStrength TrainingOtherIf you checked individual or team sports or other above, please explain in more detail here.How many times a week and for how long are you participate in the above activities?If you're not active, what are your current challenges or barriers of doing so?What other activities might you be interested in trying?Do you start exercise programs and then find it difficult to stick with them?YesNoNextWhat do you do for fun and to play?How often do you play and for how long?What other activities help you unwind and disengage from work?What are some other ways that you treat yourself (not food or monitarily related)?What is your current stress level? *NoneLowMediumHighVery HighWhat is contributing to your current stress?How do you currently manage your stress?In what ways are you engaging in self-care?On average, how much sleep do you get per night?Time you go to sleep:Do you wake up in the middle of the night:YesNoTime you wake up in the morning?Do you wake up feeling rested?YesNoWhat is your prevailing energy level?LowMediumHighIf your energy has a peak, when does that occur for you?MorningAfternoonEveningMy energy doesn't have a peakIf your energy crashes, when does that occur for you?MorningAfternoonEveningMy energy doesn't crashDo you feel energized or sluggish after meals?EnergizedSluggishWhat is your best physical atribute?If you could, what would you change about your body or physical appearance?How often do you weigh yourself?What are your initial thoughts when you see the number on the scale?If the form below looks strange, please turn your phone so your screen is wide.On a scale of 1-10, with 10 being supremely satisfied, how would you rate your happiness in each of the wellness areas below?12345678910Exercise/ MovementExercise/ Movement 1Exercise/ Movement 2Exercise/ Movement 3Exercise/ Movement 4Exercise/ Movement 5Exercise/ Movement 6Exercise/ Movement 7Exercise/ Movement 8Exercise/ Movement 9Exercise/ Movement 10Physical HealthPhysical Health 1Physical Health 2Physical Health 3Physical Health 4Physical Health 5Physical Health 6Physical Health 7Physical Health 8Physical Health 9Physical Health 10Stress LevelStress Level 1Stress Level 2Stress Level 3Stress Level 4Stress Level 5Stress Level 6Stress Level 7Stress Level 8Stress Level 9Stress Level 10NutritionNutrition 1Nutrition 2Nutrition 3Nutrition 4Nutrition 5Nutrition 6Nutrition 7Nutrition 8Nutrition 9Nutrition 10SleepSleep 1Sleep 2Sleep 3Sleep 4Sleep 5Sleep 6Sleep 7Sleep 8Sleep 9Sleep 10PlayPlay 1Play 2Play 3Play 4Play 5Play 6Play 7Play 8Play 9Play 10Body ImageBody Image 1Body Image 2Body Image 3Body Image 4Body Image 5Body Image 6Body Image 7Body Image 8Body Image 9Body Image 10Energy/VitalityEnergy/Vitality 1Energy/Vitality 2Energy/Vitality 3Energy/Vitality 4Energy/Vitality 5Energy/Vitality 6Energy/Vitality 7Energy/Vitality 8Energy/Vitality 9Energy/Vitality 10NextNextNextNextNextIs there anything else you want your Health & Wellness Coach to know?How did you hear about the Health & Wellness Coach at the CV Biblical Counseling Center?Thank you for filling out our Health & Wellness intake form. Please check this box and sign below acknowledging you are aware that ...THE HEALTH & WELLNESS COACH AT THE CV BIBLICAL COUNSELING CENTER IS NOT LICENSED OR CERTIFIED IN NUTRITION OR PERSONAL TRAINING AND DOES NOT BILL INSURANCE COMPANIES.I understand. SignatureClear SignatureMessageSubmit
