Health AssessmentDr. Eboni JanuaryHealth Assessment Form HEALTH ASSESSMENTEmail *NUTRITION GOALS AND ASSESSMENTS:Nutrition Goals Rate importance to you on a scale of 1 to 10 (1 being not important at all, 10 being very important)Drink more fluids throughout the day *12345678910Increase fruits & vegetables in my diet *12345678910Learn better food & meal choices *12345678910Learn how to control my hunger & calories *12345678910Nutrition AssessmentOn a typical day… How many meals do you eat? *12345+How many servings of fruits & vegetables do you eat? *12345+How many servings of sugar or processed foods do you eat? *12345+Are there times when you are hungry? If yes, provide details below *YesNoDetails: Dietary preferences: VeganVegetarianPescatarian (no meat, but eat fish and/or shellfish)Lactose-freeGluten-freeDiabeticOtherAre you allergic to any of the following food items? (Please select all that apply)PeanutsTree nutsSesameDairyShellfishFishEggWheat/GlutenSoyaCeleryMustardOther(Please specify): Activity Goals and AssessmentsActivity Goals Rate importance to you on a scale of 1 to 10 (1 being not important at all, 10 being very important)Gain weight *12345678910Increased energy *12345678910Improve endurance & cardiovascular health *12345678910Improve flexibility *12345678910Improve strength *12345678910Improve positive mood & feelings *12345678910Lose weight *12345678910Activity AssessmentRate yourself on a scale of 1-5 (1 indicating the lowest capacity and 5 the highest) Characterize your present cardiovascular capacity? *12345Characterize your present flexibility capacity? *12345Characterize your present muscular capacity? *12345Age: *Sex *MaleFemaleHeight (Mention in Feet & Inches) *Weight (Pounds) *Ethnicity *American Indian or Alaska NativeAsian or Pacific IslanderBlack/African AmericanHispanic/LatinoWhite/CaucasianOtherUnknown/No AnswerSmoking *Never smokedQuit smoking (more than 1 year)Quit smoking (less than 1 year)Smoked within 30 daysDoes your weight greatly impact the quality of your life? *Consider your physical comfort, body esteem, social life, and family relations.YesNoMinutes of weekly exercise Moderate activity *Minutes:Vigorous activity *Minutes:Primary care physician *I have a primary care physicianI do not have a primary care physicianIndicate if you’ve been diagnosed with any of these common weight-related conditions. (check all that apply)AsthmaObstructive Sleep ApneaGastroesophageal reflux disease (GERD)Severe urinary incontinenceNone of theseIndicate if you’ve been diagnosed with any of these other weight-related conditions. (check all that apply)Debilitating arthritisObesity-hypoventilation syndromePseudotumor cerebriNonalcoholic liver diseaseVenous stasis diseaseNone of theseDo you have diabetes? *No diabetesPrediabetesDiabetes (Type 1)Diabetes (Type 2)Waist measurement *Less than 35 inchesMore than 35 inchesIndicate any of these medications you are regularly taking. (check all that apply)Blood pressure medsCholesterol medsDiabetes medsNone of theseSystolic blood pressure *(first/top number)mm Hg:-OR estimate your range *Good - 119 or lowerSlightly high - 120 to 129Moderately high - 130 to 139High - 140 to 159Very high - 160 or higherI don’t knowDiastolic blood pressure *(second/bottom number)mm Hg:-OR estimate your range *Good - 79 or lowerModerately high - 80 to 89High - 90 to 99Very high - 100 or higherI don’t knowHow do you hear about this profiler? *WebsiteDoctor’s OfficeNewspaper AdSocial Media/Digital AdInternet SearchTV/RadioOtherWhat type of insurance do you have? *MedicaidMedicarePrivate InsurerCommercialNo InsuranceHave you received care at any of our facilities in the past? *YesNo VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: Health Assessment Form HEALTH ASSESSMENTEmail *NUTRITION GOALS AND ASSESSMENTS:Nutrition Goals Rate importance to you on a scale of 1 to 10 (1 being not important at all, 10 being very important)Drink more fluids throughout the day *12345678910Increase fruits & vegetables in my diet *12345678910Learn better food & meal choices *12345678910Learn how to control my hunger & calories *12345678910Nutrition AssessmentOn a typical day… How many meals do you eat? *12345+How many servings of fruits & vegetables do you eat? *12345+How many servings of sugar or processed foods do you eat? *12345+Are there times when you are hungry? If yes, provide details below *YesNoDetails: Dietary preferences: VeganVegetarianPescatarian (no meat, but eat fish and/or shellfish)Lactose-freeGluten-freeDiabeticOtherAre you allergic to any of the following food items? (Please select all that apply)PeanutsTree nutsSesameDairyShellfishFishEggWheat/GlutenSoyaCeleryMustardOther(Please specify): Activity Goals and AssessmentsActivity Goals Rate importance to you on a scale of 1 to 10 (1 being not important at all, 10 being very important)Gain weight *12345678910Increased energy *12345678910Improve endurance & cardiovascular health *12345678910Improve flexibility *12345678910Improve strength *12345678910Improve positive mood & feelings *12345678910Lose weight *12345678910Activity AssessmentRate yourself on a scale of 1-5 (1 indicating the lowest capacity and 5 the highest) Characterize your present cardiovascular capacity? *12345Characterize your present flexibility capacity? *12345Characterize your present muscular capacity? *12345Age: *Sex *MaleFemaleHeight (Mention in Feet & Inches) *Weight (Pounds) *Ethnicity *American Indian or Alaska NativeAsian or Pacific IslanderBlack/African AmericanHispanic/LatinoWhite/CaucasianOtherUnknown/No AnswerSmoking *Never smokedQuit smoking (more than 1 year)Quit smoking (less than 1 year)Smoked within 30 daysDoes your weight greatly impact the quality of your life? *Consider your physical comfort, body esteem, social life, and family relations.YesNoMinutes of weekly exercise Moderate activity *Minutes:Vigorous activity *Minutes:Primary care physician *I have a primary care physicianI do not have a primary care physicianIndicate if you’ve been diagnosed with any of these common weight-related conditions. (check all that apply)AsthmaObstructive Sleep ApneaGastroesophageal reflux disease (GERD)Severe urinary incontinenceNone of theseIndicate if you’ve been diagnosed with any of these other weight-related conditions. (check all that apply)Debilitating arthritisObesity-hypoventilation syndromePseudotumor cerebriNonalcoholic liver diseaseVenous stasis diseaseNone of theseDo you have diabetes? *No diabetesPrediabetesDiabetes (Type 1)Diabetes (Type 2)Waist measurement *Less than 35 inchesMore than 35 inchesIndicate any of these medications you are regularly taking. (check all that apply)Blood pressure medsCholesterol medsDiabetes medsNone of theseSystolic blood pressure *(first/top number)mm Hg:-OR estimate your range *Good - 119 or lowerSlightly high - 120 to 129Moderately high - 130 to 139High - 140 to 159Very high - 160 or higherI don’t knowDiastolic blood pressure *(second/bottom number)mm Hg:-OR estimate your range *Good - 79 or lowerModerately high - 80 to 89High - 90 to 99Very high - 100 or higherI don’t knowHow do you hear about this profiler? *WebsiteDoctor’s OfficeNewspaper AdSocial Media/Digital AdInternet SearchTV/RadioOtherWhat type of insurance do you have? *MedicaidMedicarePrivate InsurerCommercialNo InsuranceHave you received care at any of our facilities in the past? *YesNo VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: Dr. Eboni JanuaryFeatured In Please leave this field empty EAT TO LIVE Free Recipe Guide SUBSCRIBE TO GET OUR FREE HEALTHY & SMOOTHIE RECIPE GUIDE AND LEARN HOW TO EAT TO LIVE AND HEAL YOUR BODY WITH SIMPLE & DELICIOUS SMOOTHIES! 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