HEALTH SURVEY

HEALTH SURVEY

Lisa Ulm - Ulm Health & Wellness
Name *

First Name Last Name
Date *

Month Day Year
Today's date
What is your gender?
City, State
Date of Birth *
Cell phone number *
Email *
example@example.com
Preferred method of contact: *

Call Email Text
On a scale of 1-10, how motivated are you to lose weight and get healthy? *
Medical
Do you have any food allergies or sensitivities? If yes, please describe: *
Sleep
What time do you usually wake up?
What time do you usually go to bed?
Do you sleep well? *

Yes No Sometimes
Hydration
How much PLAIN water do you drink in a day in ounces? *
How much coffee do you drink in a day? What do you put in it? *
How much alcohol do you drink in a week? *
Movement
How many times a week do you exercise? *
What kind of exercise do you participate in?
How would you rate your daily energy level?
Stress
What do you do for work?
Are there other stressors in your life?
How would you rate your stress level?
Eating Habits
What time do you eat your first meal? *
How many meals per day do you eat? *
Do you snack? If yes, on what? *
How often do you eat out per week? *
Weight
What are your primary health goals?

Weight loss Feel better Learn healthy habits Other
If weight loss is your goal, how much weight would you like to lose? *
What is your height? *
Have you tried to lose weight before? If so, what program/method did you use?
What is the biggest roadblock that has prevented you from being successful losing weight? *
Thank you! I will be in touch with you shortly. You can also email me at ulmhealthandwellness@gmail.com
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Medical

Sleep

Hydration

Movement

Stress

Eating Habits

Weight