Wellness Evaluation Form
Full Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Gender
Male
Female
Health History
Height (cm)
Weight (Kilograms)
Do you have any existing medical conditions?
Yes
No
If yes, please specify
Are you currently taking any medications or supplements?
Yes
No
If yes, please specify
Have you had any recent surgeries or medical procedures?
Yes
No
If yes, please specify
Do you have any allergies?
Yes
No
If yes, please specify
Lifestyle Habits
Dietary Habits
Balanced
Vegetarian
Vegan
Gluten-free
Other
Exercise Routine
Sedentary
Light Exercise
Moderate Exercise
Intense Exercise
Sleep Patterns
Regular
Irregular
Insomnia
Other
Stress Level
Low
Moderate
High
Wellness Goals
What are your primary wellness goals?
Are there any specific areas of your health you would like to improve?
How do you envision achieving your wellness goals?
What other programs/products have you tried in the past?
How many times a day do you eat?
How many GLASSES / OUNCES of water do you drink daily?
Additional Comments or Questions
Submit
Should be Empty: