Rate the importance of these areas of wellbeing on a scale from 1-10: Not at all - Equal to what I want to achieve now - Most important thing in my life now 1 2 3 4 5 6 7 8 9 10 Assessment Form NAME EMAIL ADDRESS PHONE DOB Nutrition Weight Life Satisfaction Energy Exercise Mental and Emotional Fitness Health Life Satisfaction Energy Mental & Emotional Fitness Exercise Nutrition Weight Health Readiness to make a change A -I have no interest to make a change at this time B-I am thinking about making a change C-I am planning to make a change in 6 months D-I am planning to make a change this month E-I am ready to make a change this month How many servings of fruit and vegetables/daily Do you drink coffee tea How much DO YOU SMOKE? – cigarettes or other tobacco products? YES NO If so, how many / how often What, if any, health diagnosis are you being treated for? PRIORITIES for working with a health/wellness coach are (X all that apply): Improve well-being (health and happiness) Improve energy Increase physical activity Lose weight Improve eating habits Improve work/life balance SLEEP: I sleep: (X one) Less than 6 hours More than 6 Hours Trouble sleeping through the night Trouble falling asleep STRESS: To what extent does stress impact your life? (X one) Quite a bit Not at all Occasionally Emotions: (X all that apply) I feel calm/peaceful I am a happy person I carve out ME time I had FUN today I FELT downhearted/blue I have FELT unworthy / unimportant My interest in activities has changed EXERCISE Any physical limitations Circle one: YES NO Do you exercise regularly Circle one: YES NO How many days a week do you engage in aerobic activity How many days a week do you engage in strength training How many days a week do you engage in flexibility exercise NUTRITION Do you eat breakfast: YES NO Do you snack: YES NO How many times a day do you snack How many times a day is your snack food ‘junk’ food How many cups ( 8oz) of water do you drink, daily How many alcoholic drinks do you consume daily (liquor, wine, beer) How many soft drinks do you consume daily (8oz) What type of and how many servings of bread / grains daily (list please) Please note that this form needs to be completed and returned (at minimum) 2 days prior to your first appointment. Capital Cardiology Associates, Attn: Benita Zahn, 7 Southwoods Blvd., Albany, NY 12211 This form can also be returned via email to: [email protected]

NAME EMAIL ADDRESS PHONE Assessment Form

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Rate the importance of these areas of wellbeing on a scale from 1-10:Not at all - Equal to what I want to achieve now - Most important thing in my life now1 2 3 4 5 6 7 8 9 1 0

Assessment Form

NAME

EMAIL ADDRESS

PHONE

DOB

NutritionWeight

Life SatisfactionEnergy

Exercise

Mental and Emotional FitnessHealth

Life SatisfactionEnergy

Mental & Emotional FitnessExerciseNutrition

WeightHealth

Readiness to make a change A -I have no interest to make a change at this time B-I am thinking about making a changeC-I am planning to make a change in 6 monthsD-I am planning to make a change this monthE-I am ready to make a change this month

How many servings of fruit and vegetables/dailyDo you drink coffee tea How much

DO YOU SMOKE? – cigarettes or other tobacco products? YES NOIf so, how many / how often

What, if any, health diagnosis are you being treated for?

PRIORITIES for working with a health/wellness coach are (X all that apply):

Improve well-being (health and happiness)Improve energyIncrease physical activity

Lose weightImprove eating habitsImprove work/life balance

SLEEP: I sleep: (X one)Less than 6 hoursMore than 6 HoursTrouble sleeping through the nightTrouble falling asleep

STRESS: To what extent does stress impact your life? (X one)Quite a bit Not at all Occasionally

Emotions: (X all that apply)I feel calm/peacefulI am a happy personI carve out ME timeI had FUN todayI FELT downhearted/blueI have FELT unworthy / unimportant My interest in activities has changed

EXERCISEAny physical limitations Circle one: YES NODo you exercise regularly Circle one: YES NOHow many days a week do you engage in aerobic activityHow many days a week do you engage in strength trainingHow many days a week do you engage in flexibility exercise

NUTRITIONDo you eat breakfast: YES NODo you snack: YES NOHow many times a day do you snack How many times a day is your snack food ‘junk’ food

How many cups ( 8oz) of water do you drink, dailyHow many alcoholic drinks do you consume daily (liquor, wine, beer)How many soft drinks do you consume daily (8oz) What type of and how many servings of bread / grains daily (list please)

Please note that this form needs to be completed and returned (at minimum) 2 days prior to your first appointment.Capital Cardiology Associates, Attn: Benita Zahn, 7 Southwoods Blvd., Albany, NY 12211This form can also be returned via email to: [email protected]