Finding A Better U
Wellness Survey
Date
*
-
Month
-
Day
Year
Today's date
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred method of contact:
*
Call
Email
Text
What is your name on Facebook?
What is your Instagram Handle?
What do you do for a living?
Date of Birth
Age or Year of Birth
Medical
Are you pregnant?
*
Yes
No
If yes, are you nursing?
Yes
No
Do you have any sensitivity to soy or gluten?
*
Yes
No
Do you have any food allergies or sensitivities? If yes, please describe:
If you are taking any medications, in the box below, please let me know which medicines you are taking and what they are for.
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?
*
How much coffee do you drink in a day? What do you put in it?
How much alcohol do you drink in a week?
What else do you drink throughout the day?
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 is your main stressor?
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?
How much do you think you spend on everything you consume daily?
*
$15/day
$20/day
$25/day
Other
GOALS
Tell me a little bit about your goals.
What is your primary health goal?
*
Weight loss
Feel better
Learn healthy habits
Other
If weight loss is your goal, how much weight would you like to lose?:
If you tried to lose weight in the past, which program/method did you use?
Please list three of your main motivations or goals for wanting to lose this weight.
*
Save
Submit
Thank you! I will be in touch with you shortly. You can reach me at 484-431-8333 or barb.grajek@gmail.com
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