Health Assessment Form

Your Health Info

First Name *

Last Name *

E-mail *

Address *

City *

State *

Zip Code *

Gender *

Age *

Height *

Weight(lbs) *

Home Phone *

Cell Phone *

Fax

Please tell us how you heard about Kasper Institute and/or this assessment. Who were you referred by? *

What are your primary health concerns? *

What are your concerns, if any, about body weight? *

Have you ever been on a diet? *

If Yes, which one(s):

How high is your stress level? *

Where is your stress from, how does it affect you? *

What are your eating habits? (How many meals, size of meals, what do you typically eat?) *

Do you have any other health/heart concerns? *

If Yes, what are they?

Do you take vitamins or supplements? *

If Yes, where do you get your vitamins from?

Are you on any medications? *

If Yes to vitamins, supplements or medications, what are you taking?

What are your health/training goals? What do you want your health to be? What do you want your body to look like? *

Do you have difficulty sleeping? *

Do you have sugar or salt cravings? *

Do you have pain in your lower back, shoulders, hips, ankles on a daily basis? *

Are you exhausted at the beginning or end of your day? *

Do you normally feel depressed or angry on a daily basis? *

About Your Health: Please check off any condition that apply to you or your family

Diabetes *

Elevated Cholesterol *

High Triglycerides *

Menopause *

PMS *

Calcium Deficiency *

Breast Cancer *

Stroke *

Heart Attack *

Arthritis *

Osteoporosis *

Frequent Colds & Flu *

Allergies *

Asthma *

Alzheimer's *

Low Energy *

Liver Disease *

Kidney Malfunction *

Smoker, Current *

Former Smoker *

Alcohol/Drugs, Current *

Former User *

Lung Cancer *

Colon Cancer *

Pancreatic Cancer *

Other Cancer *

Andropause (Male Menopause) *

Under/Over Active Thyroid *

If you are a current/former smoker, how many years?

If you are a current/former alcohol user, how many years?

If yes to Other Cancer, please specify

Notes / Additional Information