Confidential Personal Wellness Assessment
Start Your Journey to Total Wellness Today.
General Information
Full Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
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Month
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Day
Please select a year
2026
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1921
1920
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
E-mail
*
example@example.com
Cell Phone
*
-
Area Code
Phone Number
Any Allergies
*
Weight
*
Height
*
Gender
Will you be using your insurance to cover the medication?
if yes, provide insurance carrier name
if yes provide insurance member ID# Group # and RXbin#
insurance information
How will you be checking in?
*
Please Select
Text message
Phone
Email
How did you hear about this program?
What are your top 3 goals for joining our program?
Health History
Are you under the care of a qualified healthcare professional? Please list.
*
Are you in good health at the present time to the best of your knowledge? Yes No
Please Select
Yes
No
Do You have a history of any of the following :
*
Diabetes type 1
Diabetes Type 2
Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease.
history of medullary thyroid cancer (MTC)
Severe hepatic/liver impairment.
History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis.
* Pregnancy, breastfeeding or trying to/planning to become pregnant.
Congestive heart failure
history of MEN 2 (Multiple Endocrine Neoplasia syndrome
*NO History of any listed above
Do any immediate family members have a history of any of the following :
Diabetes type 1
Diabetes Type 2
Severe renal/kidney impairment (with eGFR of 15 or below) or a history of renal disease.
family history of medullary thyroid cancer (MTC)
Severe hepatic/liver impairment.
History of pancreatitis, gallbladder disease, inflammatory bowel disease, diabetic gastroparesis.
Hypersensitivity to Ozempic or to any of the excipients: disodium phosphate dihydrate, propylene glycol, phenol and water for injection. .
Congestive heart failure
family history of MEN 2 (Multiple Endocrine Neoplasia syndrome
*NO family History of any listed above
What medications, supplements and over the counter items do you take regularly or are currently prescribed: ( list N/A if none)
*
Any past surgeries and hospitalizations?
*
Personal History
What is your line of work or study?
Do you exercise regularly? Please detail.
What kind of other movement or activities do you enjoy?
Do you have problems falling or staying asleep?
How many hours do you sleep?
Do you wake up refreshed?
How is your energy?
Does your energy level affect your daily activities?
How would you describe your mood, generally:
Does your mood affect your daily activities?
How would you describe your stress level?
What are your sources of stress?
How do you manage stress?
Do you have a personal support network?
Diet and lifestyle
Do you regularly drink alcoholic beverages?
If yes, how many per week?
Do you smoke tobacco?
Please Select
Yes, 1+ pack per day
Yes, 1/2 pack per day
Yes, less than 1/2 pack per day
I have quit
I have never regularly smoked
Do you use recreational drugs?
How is your appetite?
How many meals per day do you eat?
What is a typical day, in terms of food intake? Please list all meals and snacks.
How much water do you normally drink? Please approximate in ounces.
Please list all types of beverages you regularly drink.
You many times per day do you eliminate? (poop)
Please Select
Once per day
After every meal
Less than once per day
Please list any food allergies, intolerance or foods you avoid and the reason.
What past struggles and difficulties have you experienced in terms of food and dieting?
What diet and exercise programs, protocols, plans or approaches have you tried in the past?
What types of diet and exercise approaches have worked for you in the past?
And what hasn't worked for you at all?
Let's get a current picture of your health
Health History
*
Rows
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
Disordered Eating Pattern/Tendency
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headache
Lightheadednes
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Short of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Blelching/gas
Constipation
Diarrhea
Daily bowel movements
What are your top preferences for checking in?
Rows
Top choice
Works ok
Doesn't work for me
Monday morning (9am-noon)
Monday afternoon (noon-6pm)
Tuesday morning (9am-noon)
Tuesday afternoon (noon-6pm)
Wednesday morning (9am-noon)
Wednesday afternoon (noon-6pm)
Saturday morning (10am-noon)
Saturday afternoon (noon-5pm)
The above are my standard office hours of operation. If none of the above work, please list days and times that would and I will try to work something out with you.
Our goal is to assist you in implementing lifestyle modifications you want to achieve. It is recommended that you seek advice from your medical care professional for your medical needs. Information given through this program is for wellness and educational purposes and is not intended to treat or cure any disease or medical condition. You will seek advice from your medical care professional for your existing medical needs
*
I acknowledge
I understand that all information obtained through this program is for wellness and educational purposes only; that my information is private and will not be sold or shared in any way and that Fitz Six Wellness and associates are not responsible for my medical needs or concerns.
*
I acknowledge
Just one last box to write here anything important that you'd like me to know before we begin.
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