Health & Wellness Self-Assessment
www.livethehealthyouwant.com
E-mail
*
example@example.com
Full Name
*
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Height (feet/inches)
Weight (pounds)
What is your target clothing size?
What is your target weight goal?
On average, how many hours a night do you sleep?
Please Select
4 or less
5
6
7
8
9
10
11
12 or more
How many days a week do you currently exercise?
Please Select
0
1
2
3
4
5
6
7
Please rate each element of your life:
Rows
Dissatisfied to the point of being upset with myself
Dissatisfied; I must do better
Just Neutral, don't really think about it
Generally satisfied
Very satisfying and gratifying part of my life
Self-Image
Flexibility
Endurance and aerobic health
Muscle strength
Relationships
Happiness
Stress level
Diet and healthy eating
A sense of purpose
Spiritual
List all activities or hobbies you currently engage in:
List all vitamins or nutritional supplements you currently take:
Your goals
Using the video recorder below, tell us about your wellness and happiness goals for yourself. Of these goals, what is your number one goal this year?
If you prefer writing instead of filming, please include your goals here:
Submit
© StephanieShorr 2023
Should be Empty: