YOUR WELLNESS SURVEY
LET'S FIND WHAT SYSTEM WILL BEST WORK FOR YOU AND YOUR HEALTH JOURNEY. PLEASE COMPLETE THIS BRIEF SURVEY.
Name
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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.
WHO REFERRED YOU TO US?
PREFERRED METHOD OF INITIAL CONTACT:
TEXT
CALL
EMAIL
AREAS OF INTEREST AND CURRENT LEVEL OF MOTIVATION
DISCOVER WHERE YOU WANT TO BE!
DESCRIBE WHERE YOU ARE IN YOUR HEALTH RIGHT NOW... (WEIGHT, STRESS, SLEEP, 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 HEALTH JOURNEY)?
BACKGROUND
DO YOU HAVE ANY OF THE FOLLOWING?
DIABETES- TYPE I
DIABETES- TYPE II
HIGH BLOOD PRESURE
GOUT
ARE THERE ANY DIETARY RESTRICTIONS YOU CURRENTLY UTILIZE? PLEASE SPECIFY IF YOU HAVE ANY FOOD ALLERGIES?
CHECK ANY THAT MAY APPLY:
DIABETES
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
THYROID**
LITHIUM*
COUMADIN (WARFARIN)***
ARE YOU ON ANY 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 **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 MUCH SLEEP DO YOU TYPICALLY GET?
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?
HOW MUCH COFFEE?
HOW MUCH SODA?
HOW MUCH TEA?
HOW MUCH ENERGY DRINKS?
HOW MUCH ALCOHOL?
MOTION
HOW WOULD YOU RATE YOUR ENERGY LEVEL? (ON A SCALE 1 TO 10)
HOW MANY TIMES A WEEK DO YOU EXERCISE?
WHAT PHYSICAL ACTIVITY 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? (ON A SCALE 1 TO 10)
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 JOB?
WHEN AND WHERE WAS YOUR LAST VACATION?
ARE THERE OTHER STRESSORS IN YOUR LIFE?
EATING HABBITS
HOW MANY MEALS PER DAY DO YOU EAT?
WHEN DO YOU EAT YOUR FIRST MEAL?
WHEN DO YOU EAT YOUR LAST MEAL?
DO YOU SNACK BETWEEN MEALS?
WHAT TYPE 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? (ON A SCALE 1 TO 10)
DO YOU HAVE HEALTHY & ACTIVE FRIENDS, FAMILY, KEEP JUNK FOOD IN THE HOUSE, ETC?
IS THERE ANYONE IN YOUR LIFE YOU WOULD LIKE TO GET HEALTHY WITH YOU?
Submit
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