Patient Report | Revitalize Health

Patient Report

Please fill out this report in its entirety. Your responses will be used by our staff to ensure proper follow-up, supplementation, and feedback on your ongoing health plan.

When you complete this form, you will be redirected to your class video for this week.

Name*
First Last
Phone
Date*
MM slash DD slash YYYY
At which Revitalize Health location are you a patient?*
- Sugar Land
- The Woodlands
Are you doing the program with a spouse / significant other / friend?
- Yes
- No
Select which option applies to you:
- We are using the same email address to watch our videos and receive program information
- We are watching videos together but have different email addresses for the program
- We watch our videos separately with different email addresses
Great!

We want to know how both of you are doing with the steps and changes in the Revitalize Health Program. Please fill out the form below. After the first set of questions, there is a second set of questions for your spouse / significant other / friend. Please fill out both of these forms in their entirety.
Great!

If you prefer, your spouse / significant other / friend can fill out the second form located on this page underneath the first form, or they can fill out the form located in their email. It is important that they take time to fill out a form in conjunction with this class so we can know how both of you are doing with the steps and changes in the Revitalize Health Program. Completion of this form is a requirement to receive credit for your classwork.
1) Overall Energy Level
Note: 0 is lowest - 10 is highest
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
2) Hydration (Glasses per Day)
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
3) I fall asleep easily:
- Never
- 10% of the time
- 25% of the time
- 50% of the time
- 75% of the time
- 90% of the time
- Always
4) How many times do you wake up at night?
5) Are you able to go back to sleep easily?
- Yes
- No
- Not applicable
6) Are you following the diet?
- Yes
- No
- Inconsistently
7) Are you taking the supplements?
- Yes
- No
- Inconsistently
8a) Have you cheated on the diet?
- Yes
- No
8b) Explain any deviations from the diet plan:
9) Are you following the exercise plan?
- Yes
- No
- Inconsistently
10a) How many days a week do you exercise?
10b) Describe what kinds of exercise you are doing:
11) Overall, I feel like my health is:
- Worse
- Unchanged
- Improved
12) Describe how you are feeling:
13) What concerns or obstacles are you facing?
14) Number of bowel movements per day
15) Type of Stool
(see Bristol Stool Chart here)
16) Do you have any bowel concerns?
17) What benefits have you received from the program so far?
18) What do you want to keep working on?
Patient #2
Name*
First Last
Name
First Last
Email
1) Overall Energy Level
Note: 0 is lowest - 10 is highest
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
2) Hydration (Glasses per Day)
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
3) I fall asleep easily:
- Never
- 10% of the time
- 25% of the time
- 50% of the time
- 75% of the time
- 90% of the time
- Always
4) How many times do you wake up at night?
5) Are you able to go back to sleep easily?
- Yes
- No
- Not applicable
6) Are you following the diet?
- Yes
- No
- Inconsistently
7) Are you taking the supplements?
- Yes
- No
- Inconsistently
8a) Have you cheated on the diet?
- Yes
- No
8b) Explain any deviations from the diet plan:
9) Are you following the exercise plan?
- Yes
- No
- Inconsistently
10a) How many days a week do you exercise?
10b) Describe what kinds of exercise you are doing:
11) Overall, I feel like my health is:
- Worse
- Unchanged
- Improved
12) Describe how you are feeling:
13) What concerns or obstacles are you facing?
14) Number of bowel movements per day
15) Type of Stool
(see Bristol Stool Chart here)
16) Do you have any bowel concerns?
17) What benefits have you received from the program so far?
18) What do you want to keep working on?