Your Wellness Survey

Your Wellness Survey

Just a few weeks with me, yes weeks, and your life can change!
Name*

First NameLast Name
Date*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who referred you to us?
If you were referred, or you saw someone's social media post, enter their name here.
Preferred Method of Initial Contact

TextCallEmail
Areas of Interest & Current Level of Motivation

Discover where you are & 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*
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)?*
Background
Are you pregnant?*

YesNo
Are you nursing?*

YesNo
How old is your baby? *
Do you have any of the following?

Diabetes - Type 1Diabetes - Type 2High blood pressureGout
Are there any dietary restrictions you currently utilize and/or do you have any diagnosed food allergies?*

YesNo
Please describe your dietary restrictions and/or food allergies
Are you being treated for any of the following conditions or taking any of the following medications?

DiabetesHigh blood pressureHigh cholesterolThyroid**Lithium*Coumadin (Warfarin)***
Are you taking any weight loss medications, plan to, or other medications or do you have other medical conditions that could influence which program we choose?
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
***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 and wake up each day?*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
How is the quality of your sleep?*
Do you wake up feeling rested?*

YesNoOther
Describe how you feel when you wake up*
Hydration
For each of the following beverages, please enter the amount you drink each day in ounces.
Water*
Coffee*
Soda*
Tea*
Energy Drinks*
Alcohol*
Motion
How would you rate your energy level?*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
How many times a week do you exercise?*
What kind of physical activities do you participate in?*
Are there things you would like to do that you are currently unable to?*
Stress
How would you rate your stress level?*

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
What do you do for work?*
Do you enjoy what you do?*
Are there any other stressors in your life?
Eating Habits
How many meals per day do you typically eat?*
Do you snack between meals?*

YesNo
What do you snack on?*
When do you eat your first meal?*

Hour Minutes

AM/PM Option
When do you eat your last meal?*

Hour Minutes

AM/PM Option
How many times a week do you eat out?*
When you do eat out is it usually:*

Fast foodSit-downA little of both
Weight
Current Weight
Goal Weight
Height
Have you tried to lose weight before?

YesNo
What has been most difficult about losing/maintaining weight in the past?*
Surroundings
How healthy would you rate your surroundings?

1

2

3

4

5

6

7

8

9

10

1 is Very Healthy, 10 is Very Unhealthy
Is there anyone in your life who would like to get healthy with you?
Do you have healthy & active friends, supportive family, do you keep junk food in the house, etc?
Heading

Just a few short weeks with me, yes weeks, and your life can change!
Name

First NameLast Name
Should be Empty:

Your Wellness Survey

Areas of Interest & Current Level of Motivation

Background

Sleep

Hydration

Motion

Stress

Eating Habits

Weight

Surroundings

Heading