Your Wellness Survey

Wellness Evaluation

A Healthy Outside Starts From Inside
Name

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address*
City*
State*
Two Letter Abreviation
Zip Code*
Phone Number*
Date of Birth

MonthDayYear
Date
Who referred you to our program?*
If you were referred, name of person who referred you.
Preferred Method Of Initial Contact

TextCallEmail
Awaken...Discover where you are and where you want to be!
Describe where you are in your Health now... (Weight, sleep, stress, energy, etc)*

0/330
Describe where you would like to be in your Health...*

0/330
Please describe WHY you are interested in getting healthy. (What is your main Motivation...relationships, activities, how you feel, etc.)*

0/330
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?*

0/330
BACKGROUND
Are you pregnant?

YesNo
Are you nursing?

YesNo
If yes, how old if your baby?
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.
Do you have the following?

Diabetes- Type 1Diabetes- Type 2High Blood PressureGout
Are you taking any medications for:

DiabetesHigh Blood PressureHigh CholesterolThyroid**Lithium*Coumadin (Warfarin)***
*Lithium: The healthcare provider may wish to adjust the frequency of lab work for the client and monitor

**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.

***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work, and/or adjust medication.
SLEEP
How many hours of sleep do you typically get?
What time do you typically go to bed?
What time do you typically wake up?
How is your quality of sleep?
Do you wake up feeling rested?
HYDRATION
How much water do you drink each day?
How much Coffee?
How much Soda?
How much Tea?
How much Alcohol?

0/50
MOTION
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to?
STRESS
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
EATING HABITS
How many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack between meals?
What kind of snacks?
How many times a week do you eat out?
Where?
WEIGHT
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
What has been most difficult about losing/maintaining weight in the past?*

0/200
SURROUNDINGS
How healthy would you rate your surroundings? (on a scale of 1-10)
Do you keep junk food in the house, have cravings, etc?
Do you have healthy & active friends and supportive family? Is there anyone in your life who would like to get healthy with you?
Should be Empty:

Wellness Evaluation

BACKGROUND