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Hello, please fill out and submit this wellness evaluation. Looking forward to working with you!
27
Questions
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1
Name
First Name
Last Name
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2
I identify as…
Female
Male
Trans-gender
Non-binary
Other
Prefer not to say
Other
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3
Email
example@example.com
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4
Instagram Name?
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5
Phone Number
Please enter a valid phone number.
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6
Where do you live? (State ~ Country )
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7
What is your wellness/ fitness goal?
Lose weight / lower body fat %
Gain lean muscle
Increase energy levels
Healthier breakfast
Overall health
Skin care program
Enhance athletic performance
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8
How serious are you about getting results?
Very serious
I’m willing to try
I’m just curious
Type option 4
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9
Have you ever worked with a health or wellness coach?
YES
NO
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10
Current energy level on a scale of 1-10?
1
2
3
4
5
6
7
8
9
10
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11
How active are you?
Please Select
Very Active (5-7 days a week)
Moderately active ( 3-4 days a week)
Not very active (not currently exercising regularly)
Please Select
Please Select
Very Active (5-7 days a week)
Moderately active ( 3-4 days a week)
Not very active (not currently exercising regularly)
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12
How many hours a night do you sleep?
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13
Current weight
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14
How tall are you?
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15
How is you nutrition?
Poor
Normal
On point
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16
Which of the below do you skip regularly?
You may choose more than one.
Breakfast
Lunch
Dinner
Snacks
Water
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17
What do you crave the most?
Sweets
Salty
Salads/ Fruits
Fried food
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18
Do you have any food allergies or dietary restrictions?
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Small
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19
How many 8oz glasses of water are you getting in a day?
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20
How much do you spend on breakfast everyday?
$3-4
$5-6
$7-8
$10+
$0 I skip breakfast
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21
How much do you spend on lunch a day
$3-4
$5-6
$7-8
$10+
$0 I skip lunch
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22
How much do you spend on dinner a day?
$3-4
$5-6
$7-8
$10+
$0 I skip dinner
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23
How much do you spend on snacks/ coffee/ energy drinks a day?
$2-3
$5-6
$7-8
$10+
$0 I don’t snack during the day
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24
What is in the way of you reaching your goals? What have you tried in the past? What’s worked? What hasn’t & why?
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25
Check all you’re interested in.
One-on-one coaching
A plan of action
Support/ accountability group
Education
Other
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26
Which do you prefer?
Meet on zoom
Meet on FaceTime
Phone Call
Type option 4
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27
Appointment
You can also message me to schedule.
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