Wellness Form

LET'S DESIGN YOUR PROGRAM

This information will help me design YOUR program when we hop on a call.
Today's Date*

MonthDayYear
Name*
Email*
example@example.com
Phone*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Media Profile Name
Who referred you?
If you were referred, please put the name of the person who referred you OR where you saw this link.
Let's Discover Where You Are & Where You Want to Be!
What you would like to accomplish with your health? Select all that apply
Are you taking any of the following medications or have any of the following allergies? If medication/allergy/medical condition is not listed, please list in the other option.

High Blood PressureDiabetesDiabetes Type IHigh Blood PressureDiabetes Type IIGoutThyroidGluten Intolerance or AllergyLithiumCoumadin (Warfarin)Soy AllergyFood AllergiesOther
Are you Pregnant?

YesNo
Are you Nursing?

YesNoOther
Do you have any allergies or medical conditions not discussed above that could influence the system we design for you?
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc
Can you tell me about a time in your life when you were healthier? What has changed between then and now?
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?
MOTION
Are there things you can't do that you would like to do?
How many days a week do you exercise? (0-7 days)
Describe your workouts. Include length of workouts and types of workouts, i.e. cardio, weightlifting, etc.
What types of physical activity do you enjoy in general? Think movement over exercise.
MIND
On a scale of 1-10, how fulfilled are you with where you are in your health & life currently?
On a scale of 1-10, how much do you worry about your health, family, life in general currently?
What area of your life tends to be the biggest stress for you?
What do you do for work?
On a scale of 1-10, how much do you enjoy what you do?
Would you say you are more outgoing or reserved?
Would you say you are more task oriented or more people oriented?
FOOD & HYDRATION
How many meals and snacks do you eat per day?
When do you eat your first meal of the day?
How many times a week do you eat out? And where? Include beverages, snacks, etc.
The average American spends approx. $15-$20 a day/per person on groceries, beverages, supplements, snacks, dining out, etc. What would you guesstimate is your average?*

$10$15$20$25+
Do you enjoy drinking water?
Do you drink other beverages, such as:
How many ounces of water daily?
How many cups of coffee? How do you take it?
How much soda/ice tea/energy drinks/other non-alcoholic beverages daily?
How much alcohol weekly or monthly do you consume? What are your drinks of choice?
WEIGHT MANAGEMENT
What is your current age?
How tall are you?
How much do you currently weigh?
How much do you want to weigh?
Have you tried to reach these health goals in the past? If so, what have you tried?
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (Consider things like - do you have healthy and active friends, supportive family, a lot of junk food in the house, etc.)
Is there anyone in your life who you would like to get healthy with you?
Is there anything else you think we should know about your health?
Thank you for trusting me with your health goals! Now choose a time for us to talk on the phone so we can build your wellness program together!*
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LET'S DESIGN YOUR PROGRAM

Let's Discover Where You Are & Where You Want to Be!

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS