Wellness Assessment Form
I want to get to know where you are at to guide you the right way
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Occupation
Wellness Related Questions
Are you currently taking any exercise or nutrition program?
Yes
No
Height (in)
Weight (lbs)
Body Fat %
Do you drink alcohol?
Yes
No
How many times do you exercise in a week?
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
Yes
No
What do you usually eat in breakfast?
What do you usually eat in lunch?
What do you usually eat in dinner?
What snacks do you have throughout the day?
What's the hardest part about getting results?
What are your wellness goals?
Weight loss
Gain muscles
Be physically fit
Sport performance
Improve overall health
On a scale from 1-10, how serious are you about making a change? And why?
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