VIP Health Assessment

The VIP group is dedicated to helping you achieve your personal goals. In order for me to best help you I need to know a lot about you! I need to know your struggles, opinions, and triumphs.  This health assessment will help me to make the best recommendation for you based on your answers.  So please take your time and fill it out completely!

Upon completion I will be sending you my recommendation for a workout and nutrition program that is right for you and schedule a follow up meeting or phone call.  Let’s get you started!

Health Assessment Form

  • Rate yourself for each category using the rating system below to score yourself.

    0 to 3: Low energy, feeling overwhelmed, not functioning well, poor food choices, frequent use of stimulants.

    4 to 7: Feeling/performing OK; some healthy choices, room to improve, some use of stimulants.

    8 to 10: Feeling/performing well, making healthy choices, steady improvement, no use of stimulants.

  • Vitality Indicator

  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
  • Please enter a value between 1 and 10.
    (Based on the number of cups per day - the more you drink the lower your score)