Health Intake Assessment Date * MM DD YYYY Name * First Name Last Name Date of Birth * Email * Current Health Snapshot/Assessment: Please rate each category on a scale of 1-10, 1 being low and 10 being high, where you currently are today. There is no good or bad answer, just information. Please select your current rating. Movement/Physical Activity * 1 2 3 4 5 6 7 8 9 10 Sleep * 1 2 3 4 5 6 7 8 9 10 Stress Coping * 1 2 3 4 5 6 7 8 9 10 Healthy Eating * 1 2 3 4 5 6 7 8 9 10 Relationships * 1 2 3 4 5 6 7 8 9 10 Social Connection/Community * 1 2 3 4 5 6 7 8 9 10 Environment (surroundings and sustainability) * 1 2 3 4 5 6 7 8 9 10 Finances * 1 2 3 4 5 6 7 8 9 10 Career/Service * 1 2 3 4 5 6 7 8 9 10 Spirituality * 1 2 3 4 5 6 7 8 9 10 Fun/Leisure/Creativity * 1 2 3 4 5 6 7 8 9 10 Growth/Learning * 1 2 3 4 5 6 7 8 9 10 Healthcare Adherence (Visits, following prescriptions, etc.) * 1 2 3 4 5 6 7 8 9 10 What was it like for you to complete this assessment? * Thank you!
