Name Laura J Boron Date 01-04-2022
HEALTH ASSESSMENT
Address 1776 Masury Road City Masury ST OH Zip 44438 Phone (724) 977-5639
Email [email protected] Date of Birth 09-23-1963 Preferred Text
Method Call
How did you hear about our program? Cissy Dellofano Of Contact Email
AWAKEN
HYDRATION
Describe where you are in your health now. Weight, sleep, stress, energy, etc)
How much water do you drink each day? 6 bottle
212 lbs, 5 ft 0 in, high stress - husband died in
March, have several autoimmune disorders, in How much of other beverages?
pain 24/7, need help with self care, unable to do Coffee None Soda None Tea 1 cup Alcohol None
on my own! MOTION (On a scale of 1-10)
How would you rate your energy level? 8
Describe where you would like to be in your health.
Free of pain! Able to care for my self! Able to walk,
to run, to swim, to exercise, to ride bicycles, & What physical activities do you participate in?
rollerblade again! To enjoy a productive healthy Unable to
life with my boys!
Please describe WHY you are interested in getting healthy. How many times a week do you exercise? Unable to
(What is your main Motivation…Relationships, activities, how you will feel, etc)
Are there things you can’t do that you would like to be
I do not want to die! I want to live a long, able to? Everything basically
productive life with my sons! STRESS (On a scale of 1-10)
When was the last time you remember feeling your best in your How would you rate your stress level? 10
health or being at your ideal weight or size(if that's part of your goal)?
What do you do for work? Disabled
How much do you enjoy what you do? Retired RN - Loved
February of 2015
Are there other stressors in your life?
Medical Husband Died, son joined Marines in January 2021
*We recommend that clients contact their healthcare provider before starting and throughout their weight loss journey.
Are you Pregnant ? Yes No EATING HABITS
Are you Nursing? Yes No If yes, how old is your baby? How many meals per day do you eat? Small freq
Do you have the following: Are you taking any medications for: When do you eat your first meal? On waking
Diabetes
Diabetes Type 1
When do you eat last meal? 8pm
Diabetes Type 2 High Blood Pressure
Do you snack between meals? Yes
High Blood Pressure Lithium¹
Thyroid² What kind of snacks? Fruit, crackers, popsicles, yogurt, cheese
Gout
Are there any food or other allergies Coumadin (Warfarin) ³ How many times a week do you eat out? 0
that I should be aware of:
High Cholesterol Where?
Autoimmune Disorders-
NO known food allergies Polymyositis, Episcleritis! Going
WEIGHT
to Cleveland Clinic on January
Current Weight 212 lb Goal Weight 105 lb Height 5’ 0”
Are you taking other medications or do you
have other medical conditions that could
13th to see a Rheumatologist Have you tried to lose weight before? Yes
influence which program we choose:
for treatment! What has been most difficult about losing/maintaining weight in the past?
¹Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
²Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
³Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication
Cravings, time! Everything!
Research shows that there are 7
DAILY ROUTINE & HABITS significant factors that contribute
to overall physical health. SURROUNDINGS (On a scale of 1-10)
SLEEP How healthy would you rate your surroundings? 8
How many hours of sleep do you typically get? 3 (Do you have healthy & active friends, supportive family, keep junk food in the house, etc.)
What time do you typically go to bed? 12am No
Wake up? 3 am Quality of Sleep? Poor Is there anyone in your life who would like to get healthy with you?
Do you wake up feeling rested? No No
Revised 2/18/21
