Cynergy Nutrition
Health Assessment

Health Coaching Application

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Complete the following form as truthfully as possible to provide us with information about your current habits and general feeling about health and fitness. Be prepared to spend 15-20 minutes.

You have the option to Save & Continue this assessment. Please scroll to the bottom of the page and click the "Save & Continue Later" button.

Name*

First Last

Email*

Enter Email Confirm Email

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Age*

Height*

Weight*

Body Fat Percentage

if known

How do you like to eat?*

Mediterranean

Paleo

Vegetarian

Ketogenic

Fully Plant Based

Other

Daily Food & Beverage Intake*

Please share your typical daily food intake. Be very specific and complete. Include the time and what meals, snacks and beverages were consumed. Include any other items you eat such as candy, gum, etc.

How many meals do you like to eat in a day?*

What are your current exercise habits?*

Activity Level*

Please rate your daily activity level on a scale of 1-10 (not including your time at the gym). 1 being sitting at a desk and 10 being on your feet all day like a nurse or waitress.

Please enter a number from 1 to 10.

Primary Fitness / Health Goal*

lose weight

gain weight

gain muscle / improve strength

improve overall health

reduce / eliminate medications

Other

Expectations*

What are your expectations for this program and from me? Select all that apply.

Better overall health

Athletic performance

Improved body composition

Better sleep

Look good naked

Other

Other*

Medications & Supplements*

Please list any medications or supplements you are currently taking, if any. Include over the counter medications like ibuprofen.

What nutrition programs have you tried in the past?*

Select all that apply.

Weight Watchers

Jenny Craig / Herbalife

Whole 30 / Paleo

High Carb: Eat to Perform

Low Carb: Atkins / South Beach

Low Carb: Ketogenics

Macros with varying percentages

Zone

My Fitness Pal

Sugar Detox

Body-for-Life

Intermittent Fasting

Other

Please describe

If "Other" please describe.

Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/or your body?*

Yes

What have you tried?*

Which of those things worked well for you and why?*

Which of those things didn't work well for you and why not?*

How, specifically, would you like your habits, your health, your eating, and/or your body to be different?*

Out of all the changes you'd like to make, which ones feel most important/urgent?*

Does your food or weight feel out of control?*

yes

Have you ever had an eating disorder?*

yes

Do you drink alcoholic beverages?*

yes

How much do you drink?*

How many hours do you sleep?*

Do you do shift work?*

yes

How many times a week or month do you eat out?*

Eating Habits*

Describe changes, if any, that you have made to your eating habits in the past?

Fill in the blanks...

To lose weight I need to eat ...*

To lose weight I need to workout ...*

Rate the following questions using 1 as the lowest and 10 as the highest.

Rate how important changing your current health status is to you?*

Please enter a number from 1 to 10.

Rate how confident you are to make this change at this time.*

Please enter a number from 1 to 10.

If you were to consider making more changes to your habits, your health, your eating, and/or your body, what might those be?*

Barriers*

What barriers, if any, stand in the way of you achieving your nutritional/health goals?

Expectations*

What are your expectations after completing 12 weeks and how do you define success?

What are you prepared to do to work towards your goals?*

What's around you?*

Check all that apply.

Spouse or partner(s)

Roommates

Child(ren)

Pet(s)

Other family (e.g. parent, grandparent, sibling, etc.)

Do you have any children?*

Yes

How many and what are their ages?*

Who does most of the grocery shopping in your household?*

Check all that apply.

Spouse or partner(s)

Roommates

Child(ren)

Other family

Who does most of the cooking in your household?*

Check all that apply.

Spouse or partner(s)

Roommates

Child(ren)

Other family

Who decides on most of the menus/meal types in your household?*

Check all that apply.

Spouse or partner(s)

Roommates

Child(ren)

Other family

Right now, how much do the people and things around you support health, fitness, and/or behavior change?*

1 = not at all. 10 = completely.

Please enter a number from 1 to 10.

How are you spending your time?

In an average week, how many hours do you spend...

in paid employment?*

taking care of others? (e.g. children, person with a disability, older person)*

at school or doing school work?*

doing other unpaid work? (e.g. housework, errands)*

travel and/or commuting?*

volunteering?*

Adding all of these things, how many total hours per week do you spend doing all these activities?*

Given all the demands of your life, what is your typical stress level on an average day?*

1 = No stress. 10 = Extreme stress. Think about all the activities you're involved in (e.g. work, school, caregiving, housework, travel).

On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?*

1 = My life is panicked and insane. 10 = My life if perfectly calm and relaxed.

How do you normally cope with stress?*

How did you hear about us?*

Additional Information

Any additional information you'd like to share?

Cynergy Nutrition Health Assessment

Health Coaching Application

How are you spending your time?

Cynergy Nutrition
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