TrailBlazeHER Wellness Assessment
Nurturing healthy mind, body, and spirit habits - one step at a time.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number - for results and communication
*
Include extension
Age
*
35 - 39 y/o
40 - 49 y/o
51 - 59 y/o
60 + y/o
Age
I am a...(check all that apply)
*
Professional
Caregiver (to children, parents, grandparents, other)
Self-Employed
Homemaker
In Between Jobs - Seeking Employment
Other
How did you find the TrailBlazeHER assessment?
*
Facebook group
Instagram
Referral
Sent to me personally
Other
What are your top 3 physical health goals for 2025? (click all that apply)
*
Weight status
Eating Habits
Physical Activity
Sleeping
Relaxation
Safe & Healthy Surroundings
Other
How would you rate your energy level?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How much weight do you want to lose?
*
10 - 30 lbs
30 - 60 lbs
Over 60 lbs
How many years has it been since you were at your goal weight?
What activities would you like to do that you don’t do right now?
*
What are you currently doing for self-care? (Meditation, personal development, having a morning or evening routine, etc.)
How do you spend your free time?
Do you have a strong community of support?
Yes
No
Some support but I would like more
What is your primary motivation for wanting to make changes to your health (Relationships with yourself and others, activities, how you feel, Longevity, Free from disease, etc.)?
*
How committed are you to making a change in your health?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
7. What would it mean to you to be at a healthy weight and wake up every day excited and full of energy?
Do you take medication for any of the following?
*
Diabetes
High Blood Pressure
Cholesterol
Thyroid
Lithium
Coumadin (Warfarin)
Antidepressants or Anxiety meds
None
Other
What medications do you take?
Do you suffer from any of the following?
*
High Blood Pressure
Pre Diabetes
Type I Diabetes
Type II Diabetes
Gout
None
Other
I want to begin my new healthy life journey, mind, body and spirit...
*
Immediately
In less than two weeks
In more than two weeks
Not sure when
Other
Take the first step. Schedule a consultation with Coach Sheranda - https://calendly.com/trailblazeher | Follow Us on Social Media @TrailBlazeHealthandWealth
11. Do you have any of the following allergies:
*
Gluten
Soy
Eggs
Dairy
Nuts
None
Other
13. Height
14. Although your health is about a lot more than the number on the scale, if you could wave a magic wand and lose whatever you wanted to how much would you lose?
How would you rate the quality of your sleep?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How many days a week do you exercise?
None
1-3 days
More than 3 days
What type of physical activity do you enjoy?
How would you rate your stress level?How would you rate your stress level?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
How many meals do you eat per day?
*
How many snacks do you eat per day?
*
What type of snacks do you enjoy?
How many ounces of water do you drink per day?
*
How many times do you eat out per week? (Including Fast Food)
*
1-2
3-4
Daily
Never
Typically people spend between $15-$20 a day on food. How much do you believe you spend?
*
Can you identify any unhealthy patterns in your eating habits? (Midnight snacking, stress eating, eating out of boredom, etc.)
How coachable are you?How coachable are you?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Financially speaking I am...
*
Very comfortable
Have enough to meet my needs
Feel strapped
Concerned about making ends meet
Would rather not answer
My current employment is...
*
Very fulfilling
Pays the bills, but I don’t love it
Can’t quite make ends meet
Homemaker
In between jobs
Retired
Would you be interested in learning more about helping others and building a community around you?
*
Yes, very!
I am curious.
Maybe, not sure.
Not at this time
Submit
When is the best time to contact you?
*
Mornings
Afternoon
Evening
Weekend
Should be Empty: