Your Wellness Assessment from Carol

Your Wellness Survey

I'm so excited you're interested in taking your taking your health to the next level! Please fill out the survey below and I will be in touch with you on the next steps to better health! ~ Carol Holmes
First Name*
Last Name*
Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address*
City*
State*
Two Letter Abreviation
Zip Code*
Mobile Phone Number*
When were you born?

MonthDayYear
Date
How did you hear about me?*
If you were referred, name of person who referred you.
Preferred way of contact:

TextCallEmail
Where You Are Now
Describe why you are interested in getting healthy.*

0/330
When was the last time you remember feeling your best in life or being at your ideal weight or size (if that's part of your goal)?*

0/330
Where You Are Now
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)?*

0/330
Background
Do you have the following

Diabetes - Type 1Diabetes - Type 2High Blood PressureGout
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergies.

0/160
Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroid**Lithium*Coumadin (Warfarin)***
Are you taking other medications or have other medical conditions that could influence which plan we choose?*

0/185
*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?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
Are there things you can't do that you would like to be able to?
MIND
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
When was your last vacation?
Do you worry about your finances? Yes / No / Sometimes
EATING HABITS
How many meals per day do you eat?
When do you eat your first meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
WEIGHT
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?*

0/200
SURROUNDINGS
Do you have healthy & active friends, supportive family, keep junk food in the house, etc?
Are you currently on a GLP1 medication for medically-supported weight loss?
Is there anyone in your life who would like to get healthy with you?
Should be Empty:

Your Wellness Survey