Wellness Needs Assessment
The following survey provides me information about your lifestyle and goals so I can understand your needs.
Full Name
*
First Name
Last Name
Name used on Social Media
Name used on social media accounts
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
example@example.com
Who referred you to me? Enter N/A if not applicable.
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GENERAL HEALTH INFORMATION
Gender
*
Male
Female
Prefer not to answer
What would you like to accomplish in your health
*
Lose weight
Manage chronic conditions (diabetes, high cholesterol, etc)
Gain weight
Build muscle
Improve sleep
Gain energy
Learn healthy habits
Other
Do you have any of these health conditions?
*
Type 1 diabetes
Type 2 diabetes
High blood pressure
Low blood pressure
Hypothyroidism
Hyperthyroidism
Gout
Cancer
Anxiety
None
Depression
Other
Do you take any of the following?
*
Thyroid medication
Coumadin (Warfarin)
Lithium
Multivitamin
Probiotics
Diuretics
Medications for diabetes
Medications for high blood pressure
Weight loss medications
None
Other
Do you have any of the following allergies, sensitivities, or dietary considerations
*
Gluten allergies/intolerance
Soy allergies/intolerance
Vegetarian
Lactose allergies/intolerance
Pescatarian
Kosher
Vegan
Other
Are you pregnant or nursing
*
Please Select
Neither
Pregnant
Nursing
Pregnant & nursing
Trying to get pregnant
Not applicable
Do you have any other allergies or medical considerations that should be taken into account when customizing a plan for you?
Age
*
13-17
18-49
50-64
65+
Weight if known
Height if known
The following three questions: 1 - 10 (1=low / 10=high)
How do you rate your current level of energy?
*
1 - What energy?
2
3 - Below average
4
5 - About Average
6
7
8 - Above average
9
10 - I have non-stop energy!
Additional info you might want to share
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DIET & LIFESTYLE
Do you exercise?
*
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
How long do you usually exercise for?
*
10-20 minutes
21-35 minutes
36-50 minutes
51+ minutes
Not applicable
Please list the types of exercise you do regularly
How many ounces of water do you drink in a day?
*
What do you drink other than water?
Coffee
Tea
Soda
Beer
Wine
Alcohol
Other
How much do you spend on all beverages in a month?
How often do you eat out?
1-2 times per month
3-5 times per month
6-10 times per month
Less than once per month
More than 11 times per month
Never
What types of food do you eat out?
How much do you spend eating out per month?
*
Average is $10-$15 per meal eaten out.
About how much do you spend each week on food and beverages for yourself?
*
According to the 2020 census, the average American spends $420 a month ($105 per week) on personal food & drink options.
On a scale of 1-10, how happy are you with your current health?
Please Select
1 - not happy
2
3
4
5
6
7
8
9
10 - extremely happy
On a scale of 1-10, how much do you worry about your health?
Please Select
1 - all the time
2
3
4
5
6
7
8
9
10 - never
What do you do for work?
On average, do you consider your lifestyle sedentary, moderate, or active?
*
Please Select
Sedentary
Moderate
Active
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GOAL SETTING
If you could lose any amount of weight without fail, how much would you choose to lose?
*
5-10
11-25
26-50
51-75
76-100
100+
I'm not looking to lose weight
I want to gain weight
Think about the last time you were happy with your health. What has happened between then and now?
If you achieved your health goals, what would be different in your life?
What is your main motivation for wanting to make a change in your health?
Examples: Keep up with kids/grandkids, get pregnant, prepare for retirement, upcoming wedding, longevity, prepare for competition, etc.
As you prepare to achieve your health goals, do you have any friends or family members who you would want to do this with or that you would like to help get healthy?
Please feel free to forward my assessment to these people. Doing a program with a friend or family member can add extra support and accountability to help you and them succeed.
This program contains 4 components to help to achieve your goals, build new habits, and ensure lasting, long-term success. Which component are you most excited about?
Health coaching for support and accountability
Community support so I know I'm not alone
Educational resources to help me understand proper nutrition, my relationship with food, and to build lasting success
Rock solid nutrition to help me meet my goals and feel fantastic in the process
Studies show that people who mentor others are 5x more likely to achieve and maintain their own goals. As you quickly start to drop weight, many people will turn to you as a guide to help them achieve their goals. As coaches we are our own business owners, but are provided with multiple mentors and training opportunities. Are you interested in learning more about partnering as a mentor for your friends and family?
Please Select
Yes
Maybe
No
I'd need more information
On a scale of 1-10, how ready are you to start working towards your goals
Please Select
1 - I'm not ready
2
3
4
5
6
7
8
9
10 - I need this right now!
Is there anything else I should know to help me understand your needs and goals?
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