Your Wellness Survey

YOU'VE NEVER HAD THIS DAY BEFORE!!

With Rob & Jenn McDuffie
Date

MonthDayYear
Date
Name*

First NameLast Name
E-mail*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
BEST PHONE NUMBER WHERE YOU CAN BE REACHED*
Best Day/Time to Call at Above # (OPTION 1)*

MonthDayYear
Date
Hour MinutesAM/PM Option
Best Day/Time to Call at Above # (OPTION 2)*

MonthDayYear
Date
Hour MinutesAM/PM Option
Best Day/Time to Call at Above # (OPTION 3)*

MonthDayYear
Date
Hour MinutesAM/PM Option
Date of birth*

MonthDayYear
Date
How Did You Hear About Us*
If Referred,
If Other
WHAT IS YOUR WHY*
I WANT TO LOSE WEIGHT BECAUSE...
CURRENT REALITY

WHERE ARE YOU NOW?
CURRENT WEIGHT*
GOAL WEIGHT*
HAVE YOU TRIED TO LOSE WEIGHT BEFORE?*

YESNO
WHAT PROGRAMS HAVE YOU TRIED? DID ANY OF THEM WORK?*
MEDICAL
ARE YOU PREGNANT

YESNO
ARE YOU NURSING

YESNO
DO YOU HAVE ANY OF THE FOLLOWING*

HIGH BLOOD PRESSUREDIABETES TYPE 1DIABETES TYPE 2GOUTGLUTEN INTOLERANCEGLUTEN SENSITIVITYSOY ALLERGYNUT ALLERGYLACTOSE INTOLERANCEOTHER MEDICAL CONDITIONNO MEDICAL CONDITIONS
IF OTHER, PLEASE EXPLAIN
ARE YOU TAKING ANY MEDICATIONS FOR :*

DIABETESHIGH BLOOD PRESSURETHYROIDLITHIUMCOUMADIN (WARFARIN)OTHERNO MEDICATIONS TAKEN
PLEASE LIST ALL MEDICATIONS TAKEN (IF NONE TYPE NA)*
IS THERE ANYTHING ELSE WE SHOULD KNOW ABOUT YOUR HEALTH (IF NO TYPE NA)*
SLEEP
HOW MUCH SLEEP DO YOU GET PER NIGHT*

LESS THAN 3 HOURS3-5 HOURS5-8 HOURSMORE THAN 8 HOURS
HOW IS YOUR QUALITY OF SLEEP*

NOT GOODGOODBETTER THAN GOODGREAT
MOTION

EXERCISE IS NOT REQUIRED TO DO THIS PROGRAM, BUT WE DO HAVE PROGRAMS FOR THOSE WHO EXERCISE. EXERCISE WILL COME LATER, ONCE YOU HAVE REACHED A HEALTHY WEIGHT
HOW ACTIVE ARE YOU*

NOT AT ALLSLIGHT ACTIVITYVERY ACTIVE
HOW MANY HOURS A DAY DO YOU SIT*

1-45-89-1213-16ALL DAY
HOW MANY DAYS A WEEK DO YOU EXERCISE*

NONE(THIS WAS US)1-23-45-67 DAYS A WEEK
WHAT PHYSICAL ACTIVITIES DO YOU ENJOY OR WOULD LIKE TO ENJOY, ONCE YOU REACH A HEALTHY WEIGHT
FOOD & HYDRATION
HOW MANY MEALS & SNACKS DO YOU EAT A DAY(CHECK ALL THAT APPLY)*

SNACKBREAKFASTSNACKLUNCHSNACKDINNERSNACKMIDNIGHT SNACK
HOW MANY TIMES A WEEK DO YOU EAT OUT*

NEVER1-23-56-9MORE THAN 10
HOW MANY OUNCES OF WATER DO YOU DRINK PER DAY*

0-16 (ONE BOTTLE)16-3232-4848-64 (HALF GALLON)ONE GALLONMORE THAN ONE GALLON
WHAT OTHER BEVERAGES DO YOU DRINK*

SODATEACOFFEEALCOHOLENERGY DRINKSOTHER
IF OTHER
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Should be Empty:

YOU'VE NEVER HAD THIS DAY BEFORE!!

CURRENT REALITY

MEDICAL

SLEEP

MOTION

FOOD & HYDRATION

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