Health Change Assessment

Are you doing everything you can to live a long, active life? Or are you at a high risk of developing a preventable chronic illness? Are you ready change your behavior in a major way, or do you need more time to prepare yourself psychologically?

My Health Assessment is designed to help you answer these questions. It will only take a few minutes to complete, and your results will remain completely confidential.

Disclaimer: This Health Assessment is intended for educational and entertainment purposes only. It should not be construed as advice. It is not intended to diagnose or treat any medical condition or to replace the counsel of a doctor or other qualified health professional. If you suspect that you have a medical problem, please seek appropriate medical help.

Please begin by telling me a little about yourself. This information will be kept strictly confidential, and it helps us to better serve our clients.

First Name:

Last Name:
(optional)

Email:

Sex:

Male

Female

Age:

Zip Code:

What is your biggest health-related goal?

What is the biggest obstacle to achieving your goal?

What’s the most important thing a health coach could do to help you achieve your goal?

Time for a reality check. Let’s find out how healthy your lifestyle really is. Your answers will remain confidential, so please don’t fudge!

How’s your weight?

Note: If you’re not sure which category you fall into, click here to open our Body Mass Index calculator in a new window.

On an average day, how long do you exercise?

Do you smoke or chew tobacco?

Do you drink alcohol?

Note: One drink is equivalent to either 12 ounces of beer, 5 ounces of wine, or 1.5 ounces 40% distilled spirits, either straight or in a mixed drink.

What is your total cholesterol level?

What is your LDL cholesterol level?

What is your HDL cholesterol level?

What is your blood triglyceride level?

What is your fasting blood glucose level?

What is your blood pressure?

What is your resting pulse?

Please think about the health-related behavior that you most want to change. It could be smoking, overeating, eating the wrong foods, not being physically active, or something else. Next, answer the following questions in reference to that behavior.

I solved my problem more than 6 months ago.

Yes

I have taken action within the past 6 months.

Yes

I intend to take action within the next month.

Yes

I intend to take action within the next 6 months.

Yes

By taking this assessment, you’re eligible to receive a free 20-minute coaching call with Marilyn Beidler, holistic health coach and author of Everyday Wellness. Would you like to schedule a coaching call now?

Yes

If you chose “yes” above, please provide your phone number and the best time to contact you. Someone will be in touch shortly.

Phone Number:

Best Day:

Best Time:

That’s it! Please press the button below to instantly submit your Health Assessment for processing.

Health Change Assessment

Evaluate Your Health and Discover Your Stage of Change