Health Evaluation and Lifestyle Survey

Please take your time and provide as much detail as possible. I sincerely thank you for your participation.

Client Health Evaluation



    Health Concerns

    Health Hazards

    Dietary Habits and Choices

    Lifestyle, Mood and Energy

    SECTION 1 (Commercial Food): How many servings per week do you eat/drink? Check one:

    SECTION 2 (Natural Food): How many servings per week do you eat/drink? Check one:





    Steven provides health and wellness services to individuals and groups on health supporting foods and lifestyle practices to teach individuals to make good decisions to support their well being. Steven is not a Registered Dietitian or a Medical Doctor. As such, he does not provide medical nutrition services, or diagnose and treat disease. Rather, he educates people on the benefits of a healthy lifestyle to improve their quality of life. Steven advises people with existing medical problems to consult with medical doctors. Steven shares evidence-based health information, whether to class participants or wellness counseling client sessions. I agree to participate with Steven Ashton (NutritionAsRx) for nutrition education during one on one counseling sessions. My commitment is to attend as many counseling sessions as agreed upon with Steven. I understand that information provided on the relationship between nutrition and health is NOT meant to replace professional medical treatment for any health problem or condition. Health education and medical care are complementary and integrative when properly delivered. I choose to improve my health by assuming greater self-responsibility to reduce or eliminate unhealthy behaviors that are contrary to my well-being. By submitting this form, I agree to be a participant and to satisfy all above requirements.