Health & Wellness Survey
This questionnaire is designed to assess if our program can help you reach your health goals. Completing this survey will take 3-5 minutes and can completely change your life. Once you submit your survey, I will contact you with my recommendations and we can discuss how I can help you live your bet life.
Name
First Name
Last Name
Gender
Male
Female
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
GENERAL INFORMATION
What is your WHY?
What would you like to accomplish with your health? (weight loss, improved sleep, nutrition to support an active lifestyle, healthier habits, etc.)
What is your main motivation for wanting to make changes to your health? (relationships, family, activities, confidence, how you will feel, etc.)
Tell me about a time in your life when you were healthier? What changed between than and now?
Tell me about your current health: Do you have any allergies or medical conditions that could influence the program we choose for you?
What are the main reasons you are seeking a healthier you?
Weightloss
Disease Prevention
Cardiovascular Protection
Dietary Advice
Immune System
Pain Management
Detox
Digestive Support
Stress Management
Energy
Sports Enhancement
Other
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking any medications for:
Diabetes
Lithium
Coumadin (Warfarin)
High Blood Pressure
Thyroid
Other
Do you have any of the following?
Diabetes Type 1
Diabetes Type 2
Gout
High Blood Pressure
Gluten Intolerance or Sensitivity
Soy Allergy or Intollerence
Food Allergy
Other
Heading
Sleep & Energy
How many hours of sleep do you get a 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 & ACTIVITY
How would you describe the quantity & quality of activity you do each week?
How many hours do you sit in a day?
How many days a week do you exercise?
What types of physical activity do you enjoy?
FOOD & HYDRATION
How many meals & snacks do you eat per day?
When do you eat your first meal of the day?
How many times a week do you dine out & where?
How many ounces of water do you drink per day?
Do you drink other beverages? Coffee, soda, alcohol, tea etc? If so how much & how often?
WEIGHT MANAGEMENT
Are you comfortable sharing your age?
How tall are you?
How much do you currently weight?
What would you consider to be a healthy weight for you?
What has held you back from loosing the weight & maintaining weight loss?
SURROUNDINGS
On a scale of 1-10 how would you rate your surroundings? (Do you have healthy active friends, supportive family, keep junk food in the house etc?
Would you like a copy of this assessment?
Please Select
Yes
No
Submit
Should be Empty: