Wellness Assessment for Healthy Habits Lifestyles
@PausetivelyResilient
Today's Date
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Month
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Day
Year
Date
Full Name
*
First Name
Last Name
E-mail
example@example.com
Best number to reach you on
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Area Code
Phone Number
Best Days & Times to contact you
Preferred method of initial contact?
Text
Call
Email
Birthdate
Age
How did you hear about me or our programs?
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
Are there any food allergies or other allergies that I should be aware of?
Medical
We can discuss some medical considerations or prescriptions when we chat.
Do you have any of these conditions?
Diabetes- Type 1
Diabetes- Type 2
PCOS
Kidney DIsease
Gout
Sleep
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
Do you consume any other beverages?
Coffee
Soda
Tea
Alcohol
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
Walking
Running / Spinning
Dancing
Weight Lifting
Yoga
Pilates
Cross fit
Other
How would you describe your daily activity level?
Sedentary
On your feet
Active
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
What kind of health & wellness support are you interested in?
Submit
THANK YOU!!!
I will reach out to you to set up a time to chat.
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