Wellness Evaluation
C.J. Franck Health and Wellness Coach
Name
*
First Name
Last Name
E-mail
*
example@example.com
Best number to reach you on
*
Format: (000) 000-0000.
What would you like to accomplish most with your health (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Please describe WHY you are interested in getting healthy. What is your main motivation? (Relationships, activities, how you feel, etc)
Do you have the following allergies?
Gluten
Soy
Eggs
Dairy
None
Other
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Personal Information
Desired Weight
Share a bit about your life... About your family? Are you currently working? Favorite hobbies? Etc.
How do you feel (overall)?
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Healthy Sleep
How many hours of sleep do you get in a typical night?
8 or more
6-7
Less than 6
How would you describe your quality of sleep?
Do you feel rested?
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Healthy Motion
How many days a week do you exercise?
Please Select
Not at all
1
2
3
4
5
6
7
What types of physical activity do you enjoy?
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Healthy Mind
On a scale of 1 to 10 how fulfilled are you? (1 = not fulfilled; 10 very fulfilled)
What area of your life tends to be the biggest stress for you?
Do you feel good about the future of your health?
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Food and Hydration Habits
How many meals do you eat per day?
Please Select
1
2
3
4+
How many snacks do you eat per day?
Please Select
No Snacking
1
2
3
I tend to graze all day
Do you drink soda?
Please Select
Yes
1 to 2
3 to 4
5 or more
No
Do you drink alcohol?
Please Select
No
Yes
How many ounces of water do you drink per day?
16
32
48
64
More than 64oz
How many times do you eat out per week (including fast food)?
Never
1-2
3-5
Daily
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Financially speaking, I am....
Very Comfortable
Have enough for my needs
Feel strapped
Concerned about making ends meet
Choose not to answer
What do you currently do for a living?
My current employment is...
Very fulfilling
Pays the bills, but I don't love it
Cant quite make ends meet
Other
Are you interested in learning more about helping others with their health while also earning a great income?
Yes, very!
I am curious
Maybe
Concerned about making ends meet
Not at this time
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please verify that you are human
*
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