TJR Wellness Form

Name

First NameLast Name

Date

Date of Birth

Date

E-mail

example@example.com

Phone Number

Area CodePhone Number

Address

Street Address

CityState

Zip Code

Who referred you?

Preferred Method of Contact

AWAKEN...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

Describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, energy, 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

MEDICAL

Are you nursing

How old is your baby?

Do you have ANY of the following medical conditions

Do you take medication for ANY of the following?

*Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication. **Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.

Food Allergies

What are your Allergies?

SLEEP

On a scale of 1-10, rate your energy?

How many hours of sleep do you get?

What time do you go to bed?

What time to you wake up?

Do you wake up rested

HYDRATION

How many ounces of water do you drink?

How many cups of coffee or tea?

How many cans of soda/pop?

How often do you drink alcohol in a week

MOTION

How many days a week to your exercise?

What do you enjoy doing for exercise/activity?

Are there things you can not do that you would like to do?

MINDSET

On a scale of 1-10, how would you rate your stress?

What are you biggest stressors?

What do you do for work?

Do you enjoy your work?

EATING HABITS

How many times a day to you eat?

When do you eat your FIRST meal?

When do you eat your LAST meal?

Do you eat snacks?

What kind of snacks do you like?

How many times a week do you eat out and where (fast food, convenience store, sit down restaurant)?

WEIGHT

Current Weight?

Goal Weight?

Height?

Have you tried to lose weight before?

What has been the most difficult about losing and/or maintaining weight in the past?

SURROUDINGS

On a scale of 1-10, how healthy are your surroundings (work, home, community)?

Is there anyone in your life who would like to get healthy with you?

Your Wellness Survey