WFBW Wellness Discovery

Name

First NameLast Name

Contact Number:

E-mail

example@example.com

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

MonthDayYear

Sex

In case of emergency

Emergency Contact:

First NameLast Name

Relationship

Height (inches)

Weight (pounds)

Weight 6 months ago

Would you like your weight to be different? If so, what?

Taking any medications or supplements , currently?

YesNo

If yes, please list it here

Marital Status

Do you have an children?

Do you have any pets?

Occupation?

Please list your main health concerns

Please list any health goals

Any serious illness or hospitalizations

How is/ was the health of your mother?

How is/ was the health of your father?

What is your ancestry?

How is your sleep? How many hours a night?

Any pain, stiffness or swelling?

Constipation/ Diarrhea/ GI problems

Allergies or Sensitives (please explain)

Any healers, helpers, or therapies?

What role do sports and exercise play in your life?

What was your diet like as a child? Please list a typical breakfast, lunch, dinner and snack.

What is your food like these days? Please list a typical breakfast, lunch, dinner and snack.

Will family members and friends be supportive of lifestyle changes?

Do you cook? How often?

When you don’t cook, where do the rest of your meals come from?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

The most important thing I want to focus on to change my health and empower myself is:

Anything extra you would like to share?

Well Fit By Whit