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Peak Performance Wellness Center
Lifestyle Assessment Form
If a question does not pertain to your reason for scheduling an appointment, enter "NA" for your response
First Name
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Last Name
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Phone Number
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Email Address
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Birthday (mo/day/year)
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If you have a diagnosis or core issue you would like to work on list it below.
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List the primary symptom that goes with your diagnosis or core issue.
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List traumatic or shocking events throughout your lifetime and appropriate dates.
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How would you describe yourself? You can include strengths and weaknesses.
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If you take prescription medications, list each below along with how long you have taken each.
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If you take supplements, list them below.
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List any surgeries you have had.
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How many ounces of water do you drink each day? *
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How much sweaty activity do you participate in weekly?
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How many alcoholic beverages do you consume each week?
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Do you smoke?
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Yes
No
What time do you go to bed?
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What time do you wake up in the morning?
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How is your energy level?
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How much time do you spend outside each week?
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Please list any family health history that you feel would be good for me to know.
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What do you believe your body needs to be able to heal?
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What are 2-4 emotions you experience daily?
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What emotions do you typically feel when stressed?
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What are the top emotions you feel when things are going well?
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Do you have a pacemaker or other electronic implanted device?
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Yes
No
What would you like to focus on during your 1-1 consultation?
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Is there anything I have not asked about that you would like for me to know?
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