Free Wellness Assessment
Name
*
First Name
Last Name
Today's date
.
Month
.
Day
Year
Date
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number
Preferred method of contact
*
Phone
Text
Email
How would you describe your overall health? (Physical, mental, energy, confidence, etc.)
When was the last time you remember feeling your healthiest or being at your ideal weight/size (if that is part of your goal)?
Can you please describe why you are interested in getting healthy? What would would be different for you if you were to achieve your goals?
Do any of the following apply to you currently?
Pregnant
Nursing
Pre/peri menopause
Post menopause
Type 1 diabetes
Type 2 diabetes
High blood pressure
Gout
Other
If other, please add:
Are you currently on any medications?
Habits - Hydration How much water do you drink daily?
Habits - Motion How many times a week do you exercise or engage in physical activity?
Habits - Mindfulness How would you rate your stress level? (1 - 10, 10 being crazy stressed)
Habits - Sleep How many hours of sleep do you get, per night, on average?
Habits - Surroundings How satisfied are you with your current support system & community?
Habits - Eating behaviors How many meals do you eat a day? Do you snack? How often do you eat out?
Habits - Weight What is your current weight & height?
Habits - Weight What is your desired weight?
On a scale of 1 - 10, how committed are you to reaching your health goals? (10 being fully committed)
We know our programs work and can set you on the path to health, if followed properly. We'd love to help you get started and support you along the way! Is there anything else you'd like to share with us so we can have a fuller picture of how we might design a plan for you? We're excited to work with you!
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