New Client Wellness Survey

Your Wellness Survey
Full Name

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
If you were referred, name of person who referred you
Preferred method of initial contact?
Areas of Interest and Current Level of Motivation...

Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc.)
Describe where you would like to be in your Health...
Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that is part of your goal)?
Background
Do you have any of the following:
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.
Are you taking any medication for:
Are you taking other medications or have other medical conditions that could influence which program we choose?
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor client and/or adjust medication.

**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the client is on the program and adjust medication.

***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
SLEEP
How many hours of sleep do you typically get each night?
What time do you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much Coffee?
How much Soda?
How much Tea?
How much Energy Drinks?
How much Alcohol?
MOTION
How would you rate your energy level?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
MIND
How would you rate your stress level?

1

2

3

4

5

6

7

8

9

10

1 is Lowest, 10 is Highest
What do you do for work?
How much do you enjoy what you do?
If you needed an additional $500 a month, what would that take at your current employment?
When and where was your last vacation?
Are there other stressors in your life?
EATING HABITS
How many meals per day do you eat?
When do you eat your FIRST meal?

Hour Minutes

AM/PM Option
When do you eat your LAST meal?

Hour Minutes

AM/PM Option
Do you snack between meals?
If yes, list what kind of snacks
How many times a week do you eat out?
When you do eat out, is it usually fast food or sit-down?
WEIGHT
Current weight
Goal weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?
SURROUNDINGS
How healthy would you rate your surroundings?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Do you have healthy and active friends, supportive family, keep junk food in the house, etc.?
Is there anyone in your life who would like to get healthy with you?
Should be Empty:

Your Wellness Survey

Areas of Interest and Current Level of Motivation...

Background

SLEEP

HYDRATION

MOTION

MIND

EATING HABITS

WEIGHT

SURROUNDINGS