Transformational Health Centers

Overall improvement since starting care

Primary goal for this visit

Symptom quality — check all that apply

Any new diagnoses or medication changes since last visit?

Any medications reduced or discontinued since starting care?

Average sleep per night

Sleep quality

Sleep concerns — check all that apply

Current stress level

Mood & mental health — any changes since last visit?

Meals per day (average)

Fast food / ultra-processed meals per week

Fruit & vegetable servings per day

Estimated daily protein intake

Daily beverages — 1+ per day, check all that apply

Exercise frequency

Exercise breakdown

Readiness to change lifestyle to reach health goals

Therapies used since last visit — check all that apply

Compliance with prescribed home care plan

Missed appointments since last visit

Areas where you'd like more guidance or support

Overall experience with our team

Have family members had a health evaluation with us?