Health Survey Form- Ward Wellness INC
Demographics
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Time zone
Email
example@example.com
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Age
Height
Current Reality & Goals
If weight loss is one of your goals, how much weight would you like to lose to feel healthy? Please shaare your current weight as well.
What other health related goals do you have that you would like to improve or change?
How did you hear about our programs?
Please describe your WHY it is important to you NOW to becoming a healthier version of yourself. (What is your main motivation? Relationships, activities, how you feel, confidence, medical, event, etc)
If weight loss is one of your goals, when was the last time you were at your ideal weight, and what has changed since then?
Medical Questions
Are you pregnant?
Please Select
Yes
No
Unsure
Are you nursing?
Please Select
Yes
No
If nursing, how old is your baby & what are your nursing plans?
Do you have any of the following?
Diabetes- Type 1
Diabetes Type 2
High Blood Pressure
Gout
Kidney Disease
PCOS
Hypothyroidism
Other
If there is/are other health conditions you feel I should know about your health please explain below.
Do you have any food allergies or dietary restrictions?
Please list any and all medications or supplements you are taking, and what you may be specifically taking them for.
Sleep
How many hours of sleep do you typically get per night?
What time do you typically wake up?
What time do you typically go to bed?
How is your quality of sleep? Do wake feeling rested for your day?
Hydration
How much water do you typically drink per day?
Do you consume any other beverages?
Coffee
Regular Soda
Diet Soda
Alcohol
Unsweetened Tea
Sweet Tea
Milk
Juice of any kind
Current Dietary Intake & Habits
What is the first time you eat each day and give an example of what you have:
How many meals per day to you have? Snacks?
How often do you eat/dine out? Grab from fast food or convenience stores? Explain.
If you snack...give examples of your favorites. Healthy? Sweet? Salty? All of the above?
Motion
Is your work or daily routine sedentary or physical? ie sitting at desk; standing on feet; pushing; lifting; pulling
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)? Is there a time in the day where you feel sluggish?
Do you currently exercise? If so, how many times a week, duration and strenuous level:
What kinds of physical activities do you participate in?
Do you wear some kind of fitness tracker and know how to access steps per day? If you know approximately how many steps you get per day, please share.
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life that you would like to briefly share?
Is there anyone in your life who is empowered to get healthy with you?
What Actions Have You Tried in the Past?
If weight loss is a primary goal, what have you tried in the past? What did or didn't you like about it?
Have you been considering any other weight loss or health programs recently? If so please list or explain.
Would your immediate family and friends be supportive of your efforts to get healthy? Would anyone be empowered to join you in your health journey?
Thank you! I look forward to talking to you on the phone soon to share what is possible! ~In Health~ Laurie
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