Wellness Evaluation 🌱
Complete this questionnaire on your lifestyle habits. Not all questions are required.
Full Name
*
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Age
What are your health goals?
*
Fat loss
Increase muscle mass
Healthy gut
Better energy
More sleep
Weight gain
Why is this goal important to you right now?
How would you describe your current eating habits?
*
Very consistent
Somewhat consistent
Inconsistent
How many meals do you eat per day?
*
What do your meals look like in a day? List breakfast, lunch, and dinner.
*
Are all food groups in your diet?
*
Do you include snacks in your diet? If so, do you have any examples?
Do you eat at restaurants? If yes, how many times per week and what kind of restaurants?
*
If you have cravings, what are they?
Are you often bloated?
*
Often
Sometimes
Never
Do you have daily bowl movement?
Yes
No
Do you have a region of your body where fat accumulation is greater?
Do you have any diagnosed or undiagnosed eating disorders?
Do you have any skin problems that bother you?
*
Acne
Eczema
Cellulite
Stretch marks
Wrinkles or fine lines
None
Other
What is your health condition? Do you suffer from allergies, illnesses or intolerances?
*
Do you take any supplements or vitamins?
How often do you currently exercise?
*
I exercise 3+ days a week
I’m active, I walk daily or have a physically demanding job.
I don’t currently have a workout routine.
What types of movement do you enjoy?
If yes, where?
Home
Gym
Classes
Other
How is your sleep?
*
Insomnia
Frequently waking
Good
Insufficient
What do you currently use for energy?
Coffee
Energy drinks
Pre-workout
Nothing
How much coffee/tea/stimulant do you drink per day?
*
0
1
2
3+
What kind of support are you looking for?
Nutrition guidance
Movement
Mindset
Clean energy
Accountability
Other
What makes it difficult for you to achieve your goals?
Motivation
Inconsistent diet
Lack of time
No support
Other
How long are you willing to give yourself to achieve your goals?
*
15 days
30 days
60 days
90 days
1 year
Is there anything else you’d like me to know about your wellness journey?
How do you prefer to receive guidance?
Text check-ins
1:1 chat
Virtual meetings
Thank you for completing your wellness evaluation! I’ll review your responses and follow up with personalized recommendations.
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