Wellness Survey

First Name*

Last Name*

Email*

example@example.com

Date*

Today's Date

Address*

City*

State*

Two Letter Abreviation

Zip Code*

Phone Number*

Who referred you to us?*

If you were referred, name of person who referred you.

Preferred Method Of Initial Contact

TextCallEmail

Areas of Interest and Current Level of Motivation...Discover where you are and where you want to be!

Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)*

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Describe where you would like to be in your Health...*

0/330

Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)*

0/330

When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?*

0/330

Background

Do you have the following

Diabetes - Type 1Diabetes - Type 2High Blood PressureGout

Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.

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Are you taking any medications for:

Are you taking other medications or have other medical conditions that could influence which program we choose?*

0/185

*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 many hours of 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 each day?

How much Coffee?

How much Soda?

How much Tea?

How much Energy Drinks?

How much Alcohol?

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MOTION

How would you rate your energy level? (on a scale of 1-10)

How many times a week do you exercise?

What physical activities 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 of 1-10)

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 employment?

When and where was your last vacation?

Are there other stressors in your life?

EATING HABITS

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 kind 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?*

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SURROUNDINGS

How healthy would you rate your surroundings? (on a scale of 1-10)

Do you have healthy & active friends, supportive family, keep junk food in the house, etc?

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

Your Wellness Survey