Lisa Drew Wellness -  Life is a journey...Live healthy along the way!
General Assessment
At time of initial assessment, a more complete medical form is given for completion. Information is confidential and is not shared.
First/Last Name
Phone
Email
Gender
Male
Female
Age
Are you currently on a weight loss plan?
yes
no
Meals eaten per day. Please check all that apply:
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Do you drink soda?
yes
no
Do you drink alcohol?
yes
no
Do you smoke?
yes
no
Are you on medication?
yes
no
Do you exercise?
yes
no
How many times per week do you exercise?
Goals! Please check all that apply:
Lose/Gain Weight
Cardiovascular Health
Firm and Tone
Muscle Strengthen
Reduce Cholesterol
Other
Are you ready to learn how to live a healthy lifestyle?
yes
no
Are you interested in more information?
yes
no
Info for the following: Please check all that apply:
Individual
Family
Family member - child/ren
Family member - elderly
Company Wellness
Organization Wellness
Group Wellness
Fit Club
When are you looking to start your program?
How do you prefer I contact you?
phone
email
If contact by phone, what time of day is best?
Hours
 
 : 
Minutes
 
Life is a journey...Eat healthy along the way!
 
 
Website provided by  Vistaprint
Website
provided by Vistaprint