Online Wellness Evaluation Form

Online Wellness Evaluation Form

Wellness Evaluation Form
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Best Time to Call
Birth Date

MonthDayYear
Height (feet/inches)
Weight (pounds)
How did you hear about us?

How much weight do you want to LOSE/GAIN?
Why do you want to LOSE/GAIN this weight?
What other programs/products have you tried in the past?
Why do you feel that these other program(s) did not work?
What is your biggest struggle when trying to LOSE/GAIN weight?
How many times a day do you eat?
Which meal do you usually skip?
Do you have a problem with snacking? YES / NO
If yes, at what time do you have a snack attack? Daytime / Evening
What is your favorite snack?
How much do you spend on food per week?
Where do you carry most of your unwanted weight?
Do you have cellulite that you want to get rid of?
Do you take vitamins or any type of nutritional supplements currently?
How many GLASSES / OUNCES of water do you drink daily?
Do you eat out? How often? (Times/week)
Where is your energy level, on a scale of 1 to 10? (1: Dragging / 10: Bouncing)
Are you currently taking any prescription medication?
Do you regularly exercise? If YES, what type and how often?
If YES, for what?

Your Typical Daily Diet
What time do you usually wake up?
BREAKFAST (Eat & Drink)
Usual Time

:HourMinutesAM/PM Option
AM SNACK (Eat & Drink)
Usual Time

:HourMinutesAM/PM Option
LUNCH (Eat & Drink)
Usual Time

:HourMinutesAM/PM Option
PM SNACK (Eat & Drink)
Usual Time

:HourMinutesAM/PM Option
DINNER (Eat & Drink)
Usual Time

:HourMinutesAM/PM Option
EVENING (Eat & Drink)
Usual Time

:HourMinutesAM/PM Option

GOALS: WHY do you want to accomplish this? Be as SPECIFIC, DETAILED, ad VAIN as possible. How do you want your body to look and feel? Which model, actor/actress, or anyone do you want your body to look like? Do you want more confidence? Do you want to be secure in your own body? Really think about this thoroughly.
Email
example@example.com
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