The Health Hub Wellness Assessment

Welcome to The Health Hub's Wellness Assessment.

This is where your journey to optimal health begins. By completing the assessment it will help us provide you with personalised nutrition solutions to help you improve your health, feeling more energised and gaining body confidence.

Join us in paving the way to a healthier, happier you.

Talk Soon,

Charlene
Personal Information

PLEASE COMPLETE THIS FORM TO HELP US UNDERSTAND YOUR WELLNESS NEEDS AND GOALS
Name
Age
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Health History

Understanding your medical background ensures a plan that is safe.
Do you have any pre-existing medical conditions ? (If yes, please list them:)
Are you currently taking any medications? (If yes, please list them)
Do you have any allergies? (If yes, please list them)
Lifestyle

Your daily habits give us insight in what we can help you with. Small changes can make a big difference.
How many hours of sleep do you typically get per night?
Are you satisfied with your current diet? If not, why and tell me about a typical day
Do you engage in regular physical activity? (If yes, please describe)
How would you rate your stress levels on a scale from 1-10 (1 being very low - 10 being high)?
Wellness Goals

Knowing your goals helps us support you with clear, achievable steps that fit your life.
What are your primary wellness goals?
What do you hope or wish to achieve through our wellness services?
Are there any specific areas of your wellness that you would like to focus on?
List all your goals for example: weight loss, stress reduction, increasing energy, improved sleep, increasing muscle tone etc.
Thank you for completing this form. I look forward to helping you on your wellness journey.

COPYRIGHT THE HEALTH HUB (2025) - All answers are confidential and used to support your health plan. This template is protected by copyright law and may not be shared, redistributed, reproduced, or repurposed in any form without prior written consent.
Additional Information
Is there anything else you would like us to know about your wellness needs and goals?
Should be Empty:

Personal Information

Health History

Lifestyle

Wellness Goals

Additional Information