Wellness Consultation Questionnaire

Wellness Consultation Questionnaire
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Age
years
Whats the activity level at your job?
NUTRITION
Do you follow a specific eating style or diet?
If so, please state what and since when?
What is a typical breakfast?
Do you eat lots of greens on a daily basis?
On average, how many fruit juices or fizzy drinks do you have a week?
How many caffeinated beverages do you consume a day?
Do you have one within the first hour of waking up?
How many teaspoons of sugar do you have in your tea or coffee?
How many times a week do consume alcohol?
What do you snack on during the day?
Around what time in the evening do you stop eating?
Do you take any supplements?
If so, please state which ones
On average, how much water do you drink a day?
If you have any diagnosed health problems list the condition(s).
How would you rate your sleep quality?
How would you rate your energy levels when you wake up in the mornings?
How would you rate your energy levels throughout the day?
If there are any, please list any habits you've been wanting to cut out?
If there are any, please list any habits or lifestyle changes you've been wanting to bring in?
General Health
How many times a week do you exercise/move with some intensity?
Which kind(s) of exercise/movement do you do and for how long?
Please rate your readiness for change
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Should be Empty:

NUTRITION