Health & Wellness Evaluation

Full Name

First NameLast Name
Gender
Phone Number
Format: (000) 000-0000.
Email Address
myname@example.com
1. Do you eat breakfast?
2. Do you eat 3 meals per day?
3. Do you ever participate in sport or exercise?
4. What is your goal?
5. How serious are you about achieving your goal?

1

2

3

4

5

6

7

8

9

10

1 is Curious, 10 is Very serious
How old are you?
Height if known
Weight if known
What are the main reasons you are seeking wellness advice?
How do you rate your current level of health?

1

2

3

4

5

1 is Poor, 5 is Excellent
How do you rate your current level of energy?

1

2

3

4

5

1 is Poor, 5 is Excellent
How many hours sleep do you get a night?
Do you have trouble getting to sleep?
Do you have any known allergies?
Any additional info you'd like to share?
Next: Diet and Lifestyle...
Do you exercise?
Do you smoke?
How many litres of water do you drink a day?
Do you drink alcohol?
How often?
Do you often skip breakfast?
Do you get tired throughout the day?
Thank you for taking the time to fill in this Health & Wellness Evaluation!

I'll be in touch with you soon!

Jamee xx
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