WELLNESS SURVEY
Name
*
First Name
Last Name
Email:
*
example@example.com
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Evening Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
How did you hear about our health program?
If you were preferred, please tell us who referred you.
How do you prefer to be contacted?
*
Call
Text
E-mail
Social Media Messenger
Awaken...Discovering where you are and where you want to be!
Describe where you are in your health now... (Weight, sleep, stress, energy, etc)
*
Describe where you would like to be in your health...
*
Please describe WHY you are interested in getting healthy. (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's part of your goal)?
*
MEDICAL HISTORY
Are you pregnant or nursing?
*
Please Select
Yes
No
Do you have the following:
*
Diabetes - Type 1
Diabetes - Type 2
High Blood Pressure
Gout
Are there any food or other allergies that we should be aware of?
*
Are you taking medication for any of the following:
*
Diabetes
Thyroid*
High Blood Pressure
Lithium**
High Cholesterol
Coumadin (Warfarin)***
No Medicayions
Other
*Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
**Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor.
***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 daily?
How much coffee daily?
How much soft drinks/soda daily?
How much tea daily?
How much alcohol daily?
MOTION
How would you rate your energy level (on a scale of 1-10 with 10 being greatest)?
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?
STRESS
How would you rate your stress level (on a scale of 1-10 with 10 being greatest)?
What do you do for work?
How much do you enjoy what you do?
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?
How many times a week do you eat out?
Do you snack between meals?
Please Select
Yes
No
What kind of snacks do you eat?
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?
SURROUNDINGS
How healthy would you rate your surroundings (on a scale of 1-10, with 10 being very healthy)?
Do you have healthy and 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?
Are you interested in being a coach on our team?
Please Select
Absolutely!
Would like some info on this
Not at this time
What is your learning style?
Audio/Podcast
Video
Book/Jorunaling
Submit
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