Health Evaluation Form

WELLNESS EVALUATION FORM

The following questionaire is a comprehensive look at your wellness. It will take about 5 minutes to complete
Full Name

First NameLast Name
Gender

MaleFemale
E-mail
Phone Number

Area CodePhone Number

GENERAL INFORMATION
Date of Birth

MonthDayYear
Height if known
Weight if known
What are the main reasons for making a healthy lifestyle change?*

Weight lossDetoxDigestive SupportStress ManagementDietary AdviceEnergyImmune SystemSports EnhancementOther
The following three questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of health*
How do you rate your current level of energy or vitality*
How do you rate your current stress levels*
How many hours sleep do you get a night?*
Do you have trouble getting to sleep?*
Do you wake often, or get woken easily?*
Do you have known allergies?*
Please list any known allergies*
Please list any supplements you are currently taking
What is your main goal you want to accomplish?*
Additional info you might want to share
Next: Diet and lifestyle . .

Do you exercise?*

Never1-2 times a week3-4 times a week5-6 times a weekEveryday
Please list the types of exercise you do regularly
Please list any food allergies / intolerances that you are aware of?
How many glasses of water do you have a day?*

WELLNESS EVALUATION FORM