Susan Palace Wellness Survey Website Form

Wellness Survey

Excited to learn more about you and your goals. I’ll be in touch within 48 hours of receiving your form. Look forward to exploring what is possible!
Name*
Email*
Phone*
Address

CityState / Province

City/State/Zip
City/State/Zip

CityState / Province

City/State/Zip
I would love to hear what you would like to accomplish with your heatlh. Weight-loss, improved sleep, better response to stress, etc. *
What is your main motivation for wanting to make changes to your health? Relationships, activities, how you will feel, etc*
Can you tell me about a time in your life when you were healthier? What has changed between then and now?*
Tell me about your health: Do you have any allergies or medical conditions that could influence which Program we choose?*
Are you Pregnant?

YesNo
Are you Nursing?

YesNo
Are you taking any medication for:

DiabetesHigh Blood PressureLithiumThyroidCoumadin (Warfarin)NoneOther
Do you have any of the following:

High Blood PressureDiabetes - Type 1Diabetes - Type 2GoutGluten Allergy or IntoleranceSoy Allergy or IntoleranceFood Allergy (Medically Diagnosed)NoneOther
SLEEP & ENERGY
How many hours of sleep do you get in a typical night?*
How would you describe the quality of your sleep?
On a scale of 1-10, what is your energy level throughout the day?*
MOTION
How would you describe the quantity & quality of the activity you do each week?
How many hours a day do you sit?
How many days a week do you exercise? (0 - 7 days)*
What types of physical activity do you enjoy?
MIND
On a scale of 1-10, how fulfilled are you?*
On a scale of 1-10, how much do you worry?
What area of your life tends to be the biggest stress for you?
What do you do for work?*
On a scale of 1-10, how much do you enjoy what you do?*
FOOD & HYDRATION
How many meals and snacks do you eat per day?*
When do you eat your first meal of the day?
How many times a week do you eat out? And where?
How many ounces of water do you drink per day?*
Do you drink other beverages? Coffee, soda, alcohol, tea, etc.
If so, how often and how much?
WEIGHT MANAGEMENT
Are you comfortable sharing your age?*
How tall are you?*
How much do you currently weigh?*
What would you consider to be a healthy weight for you?*
Have you tried to lose weight in the past?*
What has been difficult for you about losing and maintaining weight?*
SURROUNDINGS
On a scale of 1-10, how healthy would you rate your surroundings? (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?*
Is there anything else you think I should know about your health?*
Should be Empty:

Wellness Survey

SLEEP & ENERGY

MOTION

MIND

FOOD & HYDRATION

WEIGHT MANAGEMENT

SURROUNDINGS