Wellness Coaching Questionnaire

Wellness Profile!

214-833-0772 for Qs
Full Name *

First Name Last Name
Gender

Male Female
Email
example@example.com
Phone Number *

Area Code Phone Number
Age
years
I am interested in:
How can I follow you?
Please label Instagram, Twitter OR Facebook
What do you do for a living? *
Student? Job Title? Place of Employment?
What are your goals? *
(ie. to lose/gain weight. to gain confidence at work. to create better relationships. to feel better physically. to maintain my current healthy self.)
Have you tried to reach this goal before and how did it work out? *
What is your daily stress level? *

None (easy peasy) Moderate (light) High (heavy)
What is your outlet? *

Exercise & Fitness Creative Social Gaming
Do you eat 3 meals a day?

Yes No
How many days a week do you exercise?

1-3 3-5 over 5
How much water do you drink daily?

1 glass 2-3 glasses full gallon always what's water?
When are you the most tired?

Right when I wake up Mid-day After work
Please rate your readiness for change.

1 2 3 4 5 6 7 8 9 10
Why?
Please give me a few details of your story. I want to equip you with the very best tools customized to specifically help you grow!
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Wellness coaching is a function of support only and not a diagnosis of any physical malfunction within any specific area. Coaching sessions are intended to provide informative guidance and voluntary options only. Products suggested by Missy Payne or the staff of Well on Wheels are not intended to diagnose, treat, cure or prevent any disease or condition. If you are concerned about your physical or mental capacities from a medical perspective, you should seek the help of a qualified health professional.
PLEASE TYPE: "(Your full name) has READ & UNDERSTAND"
I am voluntarily participating in the Well-on-Wheels programming in Dallas, TX. I understand that in all athletic activities, there is an inherent risk of injury while participating. I do hereby release and for ever discharge Missy Payne aka Well on Wheels, Cheer 4 Your Life 501(c)3, officers, agents, employees, its subsidiaries, affiliates, nominees, successors, licensees, and assigns and those acting with authority, including each of the respective employees, agents, officers and directors from any and all claims, demands, and causes of action for injury to myself or my property arising from participation. I further attest and acknowledge that I am in good health condition and can physically participate in all activities that require physical exertion. I am irrevocably giving permission to Missy Payne to take and use photographs, video or sound recordings of myself for promotion, advertising, trade and/or any other purpose in group exercise or leadership workshops.
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Wellness Profile!

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