Wellness Questionnaire

Wellness Questionnaire

Essential Era Wellness Clinic
Full Name*

First NameLast Name
MaleFemale
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Age
years
Height
cm
Weight
KG
What do you do for a living?
None (seated all day)Moderate (light activity such as walking)High (heavy labor, very active)
How many pounds would you like to lose/gain, or what is your health goal?
What have you tried before and why did it not work for you?
YesNo
BreakfastLunchDinner
YesNo
1-33-5over 5never
1 glass2-3 glassesfull gallon alwayswhat's water?
TeaJuiceSodaCoffee/Energy Drinks
Right when I wake upMid-dayAfter workOther
12345678910
Why?
AccountabilityJust starting!I've hit a plateau & I need to change thatOther
YesNo
CallTextEmailOther
Thank you for reaching out to Essential Era Wellness! We're excited to support you on your wellness journey. We'll be in touch within 48 hours to get started. Looking forward to working with you!
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