Health Assessment

The following health assessment is to help identify health and nutrition weaknesses. It is not intended to diagnose or provide a cure for any condition(s), but is intended to be educational. Health and nutrition suggestions and guidelines will be provided according to the results of the assessment.

Please select all that apply within the last 30 to 60 days:

What is your sex?
Male
Female

What is your age group?
Under 18
19 to 30
31 to 50
Over 50

Depression and Anxiety
1 . depression, negativity, apathy, including postpartum for women
2 . use an antidepressant
3 . anxiety, worry, fear, phobias, panic disorder, or panic attacks
4 . take medication to help with anxiety
5 . obsessive thoughts or behaviors, OCD
6 . perfectionism or controlling behaviors
7 . suicidal thoughts
8 . seasonal affective disorder or winter blues
9 . low self-esteem
10 . take Prozac or similar serotonin-boosting drugs

Mental Clarity
11 . fuzzy thinking, foggy headed, lack of focus, difficult to concentrate, short term memory loss
12 . ADHD, ADD, hyperactivity, or manic-depression
13 . feelings of restlessness or unable to relax or loosen up

Energy, Endurance, and Strength
14 . often feel tired, fatigued, have a lack of energy, endurance, and/or muscular weakness
15 . fatigue is not relieved by sleep
16 . frequent sighing and yawning
17 . sleepiness or drowsy
18 . wired but tired feeling
19 . have to force yourself to do even moderate exercise
20 . find it hard to get going in the morning
21 . difficulty getting up in the morning
22 . morning sluggishness
23 . often feel stressed, overwhelmed, and exhausted
24 . lose energy around 2-5 PM
25 . lose energy between 5-9 PM
26 . more energy or more awake at night (Second Wind)
27 . feel stressed/less tolerant
28 . thrill seeking behavior
29 . high levels of endurance or stamina
30 . loss of muscle mass
31 . bone loss (osteoporosis)
32 . use food, caffeine, tobacco, and/or other stimulants for energy

Sleep
33 . difficulty falling asleep
34 . difficulty staying asleep
35 . sleep disturbances, insomnia
36 . frequent daytime naps, nap hangover, ability to fall asleep anytime
37 . get to bed after 10:30 PM
38 . night sweats

Pain
39 . headaches or migraines
40 . chronic pain
41 . painful or tender breasts
42 . sores on legs that take a long time to heal
43 . breast tenderness
44 . bladder infections
45 . increased infection
46 . aches/pains muscles
47 . aches/pains joints
48 . swollen/painful joints
49 . migratory muscle, joint, or nerve pain
50 . rashes

Weight
51 . regain weight after dieting, more than was lost
52 . can gain weight without overeating; hard to lose weight
53 . can’t gain weight
54 . weight gain in hips
55 . increased abdominal fat or abdominal weight gain
56 . constantly think about weight

Discomfort
57 . heart palpitations, irregular heartbeat, experience dizziness
58 . overactive or leaky bladder
59 . day sweats
60 . trembling or twitching muscles or eyes
61 . worsening allergies
62 . gallbladder problems (occasional sharp pain on right side under rib cage, or pain between shoulder blades)
63 . unexplained or persistent cough
64 . flushed face
65 . candida/yeast
66 . yeast infections
67 . deepened voice
68 . hemorrhoids/ varicose veins
69 . can’t catch breath, “air hunger” or panic attacks that leave you breathless
70 . breast swelling
71 . tingling, numbness, burning, or stabbing sensations

Food Cravings
72 . crave salty foods, sweet foods, or need caffeine for energy boost
73 . afternoon or evening food (sugar/salt), alcohol, or other substance cravings
74 . increased cravings for and focus on food; overeating
75 . crave a lift from sweets or alcohol, but later experience a drop in energy and mood after ingesting them
76 . salt cravings
77 . sugar cravings or increased appetite
78 . crave milk, ice cream, yogurt, cheese, or doughy foods (pasta, bread, cookies, among others) and eat them frequently
79 . crave chips, cheese, and other rich foods more than, or in addition to, sweets and starches

Food Nutrition
80 . usually eat less than 2,100 calories a day
81 . under-eat or often prefer beverages to solid food
82 . eat mostly low-fat carbohydrates
83 . consume aspartame, (NutraSweet), diet colas, or other diet sweeteners frequently
84 . vegetarian
85 . bulimia or anorexia

Food & Blood Sugar Stability
86 . dizzy, weak, or headachy, especially if meals are delayed
87 . nervous, jittery, irritable, headachy, weak, or teary on and off throughout the day; calmer after meals
88 . feel shaky, weak, or irritable if meals are skipped
89 . low energy or drowsiness, especially after meals
90 . skip meals, especially breakfast

Food Allergies
91 . allergic to milk products or other common foods
92 . food allergies in family

Medical History
93 . diagnosed with Fibromyalgia, Chronic Fatigue Syndrome or TMJ
94 . diagnosed with autoimmune disease like Rheumatoid Arthritis, Lupus, or Multiple Sclerosis
95 . family history of diabetes, hypoglycemia, or alcoholism
96 . used antibiotics extensively (at any time in life)
97 . use or have used birth control pills, cortisone, or other hormones medications
98 . received a tick or mosquito bite immediately followed by flu like symptoms
99 . ongoing dental issues like painful/bleeding gums, gingivitis, dead teeth, root canals
100 . recurring sinus or ear infections as an adult or child
101 . respiratory problems (asthma, postnasal drip, congestion)
102 . had your gallbladder removed
103 . history of hepatitis, other liver problems
104 . high cholesterol
105 . low blood pressure and/or low heart rate
106 . high blood pressure or increased heart rate
107 . blurry vision or failing eyesight
108 . Please list any supplements and medications that you currently take

Bowel Movements and Elimination
109 . stool unusual in color, shape, or consistency
110 . light-colored stool
111 . hard or foul-smelling stool
112 . bowel movements less often than once a day

Sensitivities
113 . sensitive to loud sounds, strong odors, or bright lights

Stomach and Digestion
114 . stomach issues (diarrhea, constipation, indigestion)
115 . chronic constipation and/or diarrhea
116 . nausea
117 . bloating, abdominal distention
118 . bloating, water retention
119 . bloating after meals
120 . gas, belching
121 . avoid food or throw up food because bloating after eating makes you feel fat or tired
122 . digestive discomfort of any kind
123 . feel heavy, uncomfortable, and “clogged up” after eating fatty foods
124 . indigestion, ulcers, GERD

Emotions
125 . low self-esteem
126 . decreased self-esteem
127 . cry or tear up easily
128 . crying spells
129 . weepy or teary
130 . crying for no reason
131 . moodiness, irritability, rage, or anger
132 . aggressive or irritable
133 . intense/violent dreams
134 . decreased ability to handle stress (irritable, less tolerant)

Lifestyle
135 . decreased sex drive or low libido
136 . dislike hot weather
137 . frequent thirst or urination
138 . have ancestry that includes Irish, Scottish, Welsh, Scandinavian, or coastal Native American
139 . alcoholism and depression in the family history
140 . easily chilled (especially hands and feet)
141 . feeling cold
142 . other family members have thyroid problems
143 . difficulty swallowing pills or substances or lump in throat
144 . light-headed when you stand up quickly
145 . fewer dreams
146 . excess facial/body hair

Skin, Hair, and Nails
147 . dry skin and /or eyes
148 . oily skin/hair
149 . skin tags
150 . skin bruises easily
151 . eczema or thin skin
152 . have chronic fungus on nails or skin or athlete’s foot
153 . weak, brittle nails and/or dry, coarse skin or hair
154 . increased acne
155 . sparse eyebrows and/or eyelashes
156 . hair loss, thinning scalp hair, or alopecia (not male pattern baldness)
157 . pink to purple stretch marks on belly or back
158 . increased perspiration

Women only
159 . premenstrual mood swings
160 . premenstrual or menopausal food cravings
161 . irregular periods
162 . uncomfortable periods cramps, lengthy or heavy bleeding, sore breasts
163 . skin eruptions with period
164 . Polycystic Ovary Syndrome (PCOS)
165 . vaginal dryness/irritation
166 . heavy or painful periods
167 . endometriosis
168 . hot flashes
169 . cysts (ovarian, breast, etc.)
170 . heavy or painful periods
171 . night sweats
172 . miscarriage (first trimester)
173 . infertility
174 . irregular or absent menstrual cycles
175 . light/absent periods
176 . mid-cycle pain
177 . ovarian cysts
178 . currently use birth control pills, IUD, patch, ect.
179 . have ever used birth control pills, IUD, patch, ect.
180 . currently use cortisone, bio-identical hormone replacements, or other hormone medications
181 . have ever used cortisone, bio-identical hormone replacements, or other hormone medications

Men only
182 . reduced muscle mass or muscle atrophy
183 . increased abdominal fat or abdominal weight gain
184 . male pattern baldness
185 . erectile dysfunction
186 . infertility
187 . increased carbohydrate cravings and consumption
188 . bone loss or reduced bone density
189 . moodiness or lack of motivation
190 . enlarged breasts
191 . enlarged prostate
192 . urinary or prostate problems

Health Concerns
193 . Please list your top three health concerns

A health and nutrition consulting session is $45 an hour. A typical session is about 1.5 hours.
I work out of my home office in Riverton and my typical hours are M-F 9 AM to 4PM.
If you are interested in scheduling a session, please enter your best contact info below.

Natalie
Certified Exercise Physiologist, ACSM
Certified MSA Practitioner
Health Fitness Specialist
Nutrition Consultant

 

Name: (Optional, for personalized results)

Assessment results will be emailed to: