Wellness Coaching Questionnaire

Wellness Profile!

Your Wellness Journey Starts Here
Full Name*

First NameLast Name
Gender

MaleFemale
Age
years
Email
example@example.com
Phone Number
Height
ft/in
Weight
lbs
What is your desired weight?
Do you have any medication/latex/food allergies? If yes, please list.
List any Medications you take:
List any Supplements you take:
Do You Have any Health Issues:

DiabetesHeart DiseaseHigh Blood PressureLiver DiseaseKidney DiseaseCOPDThyroid DiseaseAutoimmune DiseaseJoint Pain/AchesStiffness or Limitation in MovementTremor or Restless legFatigue/ Low EnergyRestlessnessBrain FogHeadaches/ MigrainesSeasonal AllergiesAcneHeavy or Painful PeriodsFlushing or Hot flashesExcessive sweatingLow libidoHair lossOther
Have you had any hospitalizations, surgeries, or are missing any body parts (such as gallbladder, appendix, etc)?
Women Only
Are your menstrual cycles regular?

YesNo
Are you on birth control?

YesNo
Are you pregnant?

YesNo
Are you on hormone replacement therapy(hrt)?

YesNo
Do you experience symptoms of PMS (cramps, water retention, etc.)
Are you in Perimenopause/ Menopause?

YesNoWhats that?
Estimated, about how many courses of antibiotics have you had in your life?
Have you ever had any mercury amalgams or root canals?
How often do you have a bowel movement? How is the consistency and color? (ex:brown, solid)
Have you had any remarkable exposure to toxins such as from your childhood home, work place, living close to an industrial community, pesticides, metals or mold?
At what point in your life did you feel your best and why?
What is your health goal?
What have you tried before and why did it not work for you?
Sleep Profile
How many hours do you sleep at night?
Do you have difficulty falling asleep, staying asleep, or waking frequently throughout the night?
Rate Your Sleep Quality:

PoorFairGoodExcellent
When are you the Most Tired?

Right when I wake upMid-dayAfter workOther
Overall how is your energy?
On Average how many nights a week do you get quality sleep?
What do you do for a living?
Whats the activity level at your job?

None (seated all day)Moderate (light activity such as walking)High (heavy labor, very active)
How many hours per week?
Any major life concerns outside of health and nutrition?
What Stressors do You have?

WorkRelationshipsChildrenFinancesOther
How do you Cope with Your Stress?
From 0-10 how would you rate your stress level?
What do you do for fun?
Nutrition Profile
On a scale 1-10 how would you define your current diet and why?
What was your nutrition like as a child?
Do you have a mindset or approach when it comes to food?
Do you eat 3 meals a day?

YesNo
If No, which meals do you skip?

BreakfastLunchDinner
Do you generally snack?

YesNo
What percentage of your meals are being eaten at home, cooked from scratch?
How many days a week do you eat out?

1-33-5over 5never
How much water do you drink daily?

1 glass2-3 glassesfull gallon alwayswhat's water?
What else do you currently drink?

TeaJuiceSodaCoffee/Energy DrinksAlcohol
Please check any of the items that you consume regularly (within the last month)

Artificial SweetenersLunch Meats/ Hot DogsRefined flours/breadsProcessed Foods: Chips, Debbie Cakes, Any Boxed foodsTap WaterBinge Eating/ Drinking
How many cups of vegetables do you consume per day?
How many servings of grain per day?
How many ounces of protein do you consume per meal?
What are your favorite foods?
Are there any foods that you dislike or that you do not eat?
Do you crave certain foods on a consistent basis?
What are 3 unhealthiest foods that you consume regularly?
Do you experience symptoms after eating meals such as (bloating, belching, vomiting, etc.)
Any history of disordered eating?
From 1-10, how willing are you to make dietary and lifestyle changes?
Do you have family and friends that are supportive of you with making lifestyle and dietary changes?

YesNoOther
Movement Profile
How many days do you have physical activity outside of work/house hold chores?

one3-5everydaynone
What type of physical activity?

WalkingRunningSwimmingLift WeightsHIITPilates/ YogaOther
Please rate your readiness for change. 10= Ready YESTERDAY!

12345678910
Why?
What do you need the most help with?

AccountabilityJust starting!I've hit a plateau & I need to change thatOther
If you could wave a magic wand and change two things in your life, what would they be?
Are you willing to financially commit to changing your life?*

YesNo
How do you prefer to be contacted?

CallTextEmailOther
I am so excited that you decided to reach out to me to help you with your wellness goals! I can't wait to work with you! I'll reach out within 48 hours!
Should be Empty:

Wellness Profile!

Women Only

Sleep Profile

Nutrition Profile

Movement Profile