Wellness Survey

Welcome to Exploring Optimal Health!
Emma Clark

Certified Independent Health and Business Coach
Congratulations on reaching out to discover how you can create a lasting TRANSFORMATION in your LIFE with your health. Thank you for taking time to fill out the survey. I am excited to discuss with you the best program that will fit your health needs and goals.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Age
How did you hear about me or the program I coach?
Please describe your WHY to becoming a healthier version of yourself. (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)
How do you want to feel when you reach your health goal?
What are some activities, vacations, or tasks you would like to do when you reach your health goal?
Medical Questions
Are you pregnant?
Are you nursing?
If yes, how old is your baby?
Do you have any of the following?

Other
Do you have any food allergies or dietary restrictions?
Please list any and all medications or supplements you are currently taking:
Are you taking any medications for?
Sleep
How many hours of sleep do you typically get per night?
What time do you typically wake up?
How is your quality of sleep? Do you feel rested when you wake up?
Hydration
How much water do you typically drink per day?
Do you consume any other beverages?

Other
Motion
How would you rate your daily energy level on a scale of 1- 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical activities do you participate in?
How would you describe your daily activity level?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
What time do you usually wake up?
When do you usually have your first meal of the day?
What do you usually eat for your first meal?
When is the next time you have something to eat, including a morning snack?
If you have a morning snack, what do you usually eat?
What time do you usually have lunch? What do you eat at lunchtime?
When is the next time you eat something, including an afternoon snack? What do you snack on in the afternoon?
What time do you eat dinner?
What do you usually eat for dinner?
Do you eat a snack or dessert after dinner? What do you usually eat?
What time do you go to sleep?
If you had the choice between chips or a brownie, which would you choose?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
What are your favorite restaurants/coffee shops/bars to eat out or get takeout?
Weight
Current Weight: (if you wish to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who is empowered to get healthy with you?
Should be Empty:

Welcome to Exploring Optimal Health!

Emma Clark

Medical Questions

Sleep

Hydration

Motion

Stress

Eating Habits

Weight