RENEWAL Assessment

This RENEWAL Assessment is for those who want to learn the top 3 things they can do for their health, or for those who want a complete Natural Health Plan. You will be brought to the payment options after completing the assessment. Michelle Greenman personally reviews each one.

You Can Also Download the RENEWAL Assessment

Payment is waved for coaching and group clients.

Please be as thorough as you feel comfortable.

Fill in with as much information as you feel comfortable sharing.
Contact Information
Your Name(required)
Email(valid email required)
Address
Phone Number
City Town, Country of Address
Health Information
What are your current Health Concerns
What treatments have you tried for your current concern?
Other Past Diagnoses
Do you sleep well?
What is your Stress Level
Any pain, stiffness or swelling?
Have you suffered from depression or anxiety?
Do you suffer from Constipation/Diarrhea/Gas?
Medical Information
Age
Sex
Height (ft. in.)
Weight (lbs.)
Desired Weight (lbs.)
How is/was the health of your mother?
How is/was the health of your father?
What is your ancestry?
Social Information
At what point in your life did you feel best?
Relationship status:
Children:
Pets?
Occupation:
Hours of work per week:
What role do sports and exercise play in your life?:
Annual Household Income
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?:
How often do you check e-mail:
Lifestyle Information
Your daily schdule: (when you wake up, eat, go and sleep)
Fill in the Average Amount
Water drank a day?
Hours of Sleep a night?
Minutes of Aerobic Exercise (a day)?
List the pharmaceutical drugs are you currently taking.
List the supplements are you currently taking.
Do you have any addictions?
Diet Information
Typical Day Diet Recall (include times):
How often do you eat out?
Where do you shop for food?
What are your favourite foods?
What are your least favourite foods?
What foods are you allergic to?
In the last 7 days...
Time out side during the night?
Time outside during the day?
How many days have you exercised?
Have you exercised outside in the last week?
Have you attended in a religious meeting?
In the last 3 weeks...
Did you drink alcoholic beverages?
Did you drink caffeinated tea?
Did you drink coffee?
Did you drink herbal teas?
Did you eat red meat more than once?
Did you eat fish more than once?
Did you eat eggs more than once?
Did you consume dairy products more than once?
Which Program(s) are you interested in?
Optimal Lifestyle Assessment OPTIMAL HEALTH PLAN Weight Loss COACHING
The most important thing I should change about my diet to improve my health is
Additional Notes: Anything else you would like to share
What color is snow?
Upload Blood Work Report

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