HEALTH ASSESSMENT QUESTIONAIRE

Please fill out the following form to help me understand your physical condition.

First Name

Email Address

Phone

Please list all of your concerns about health, eating habits, fitness and/or body.

Last Name

Date of Birth

Preferred method of contact?

Email

Mobile

Text

Video

Gender

Male

Female

Today's Date

In general what are your goals?

Lose weight

Gain weight

Maintain weight

Gain Muscle

Improve Physical Fitness

Look better

Feel better

Have more energy/vitality

Control Eating Habits

Get stronger

Train for a competition

Imp athletic performance

On a scale from 1 – 10 (10 being the most ready), how ready are you to make the necessary changes to meet your health goals?

What do you expect from me as your coach?

Have you tried anything in the past to change your habits, health, eating, body?

Which of these things have worked well for you?

Thanks for submitting!

MARLA TURNBULL

NATIONAL BOARD CERTIFIED HEALTH & WELLNESS COACH

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Stakeholder Advisory Board for University of Pittsburgh Patient Centered Outcomes Research for Sepsis & Pneumonia

JUICE PLUS

MARLATURNBULL.JUICEPLUS.COM

Disclaimer: Neither are the meal plans or nutrition information intended to be understood as putting forth any cure for any type of acute or chronic health problem. You should always consult with a competent, fully licensed medical professional when making any decisions regarding your health.

CONTACT ME • PITTSBURGH, PA 15238 • 412-302-4638 • MARLA@NATURESDIVINEHEALING.COM

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