Client Weekly Health Check-In Form

Track weight, sleep, habits, and any unusual symptoms each week to monitor a patient's or employee's physical condition.

Use this template

Check-In Date & Time

Patient Name

First Name

Last Name

Age

Gender

Female Male Other

Phone Number

Email

Address

Street Address

City

State / Province

ZIP / Postal Code

Height (cm)

Weight (kg)

What are you health goals this week?

What kind of lifestyle do you have?

Active Sedentary Moderately Active Athletic

How many hours of sleep do you get daily?

How often do you exercise every week?

Do you smoke?

Yes No

What type of a smoker are you?

Occasional Regular Heavy

Do you drink alcohol?

Yes No

Do you feel any not normal within your body physically?

Yes No

Please tell us more about it

Comments, suggestions, or feedback

Patient Signature

Sign here

Date Signed

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