THE WELLNESS BLUEPRINT™
Personalized Online Wellness Assessment
Kerry Lewis, LMT
Creator of The Wellness Blueprint™
Welcome
Thank you for your interest in The Wellness Blueprint™.
This personalized online wellness consultation is designed for individuals who are ready to make intentional, sustainable improvements to their health and well-being.
My goal is not to overwhelm you with dozens of changes. My goal is to help you identify the changes that will have the greatest impact on your health, while offering practical, realistic strategies that fit your lifestyle.
Every Blueprint is thoughtfully created based on your goals, lifestyle, habits, challenges, and priorities.
This is an educational wellness service and is not intended to replace medical care or advice from your physician or other licensed healthcare provider.
Investment
Initial Online Wellness Consultation + Your Personalized Blueprint
$175
Your investment includes:
✔ Comprehensive review of your Wellness Assessment
✔ Individualized evaluation of your current lifestyle and wellness goals
✔ Your customized Blueprint
✔ One follow-up email if clarification is needed regarding your recommendations
Optional Blueprint Review
$75
Recommended every 8–12 weeks
During your follow-up, we’ll:
• Review your progress
• Celebrate your successes
• Discuss any challenges you’ve encountered
• Adjust your Blueprint as your goals evolve
• Establish your next priorities
Building lasting habits takes time. These follow-up consultations are optional, but encouraged for continued support and accountability.
Payment
After reviewing your completed Wellness Assessment, I will contact you when I am ready to move forward with creating your personalized Blueprint.
Once confirmed, a payment request will be sent.
Payment must be received before I begin creating your Blueprint.
Accepted payment methods:
• Venmo
• PayPal
• Cash App
• Meta Pay
Please allow approximately 3–5 business days after payment has been received for your Blueprint to be completed and emailed to you.
Before You Begin
The quality of your Blueprint depends entirely on the information you provide.
Please answer every question honestly and thoroughly.
This is a completely judgment-free space.
There are no perfect diets.
No perfect exercise routines.
No perfect lifestyles.
I’m not looking for perfection.
I’m looking for honesty.
Your recommendations will be based entirely on the information you provide. The more transparent you are about your lifestyle, nutrition, stress, sleep, movement, medications, supplements, health concerns, and goals, the more personalized and effective your Blueprint will be.
The better I know you, the better I can help you.
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City & State
*
Occupation
Emergency Contact
Your Why
What are your top three wellness goals?
If you could improve only one area of your health over the next 90 days, what would it be?
Why are you seeking a wellness consultation at this time?
If nothing changed over the next five years, how would that make you feel?
If you successfully reached your health goals, how would your life look different?
What does success look like to you?
Current Health Snapshot
How would you rate your current health?
*
Poor
Fair
Good
Very Good
Excellent
How would you rate your current stress level?
*
Very Low
Low
Moderate
High
Very High
How many hours of sleep do you average each night?
*
Do you wake feeling rested?
*
Yes
No
Sometimes
Nutrition & Hydration
Describe your current eating habits
Approximately how much water do you drink daily?
Do you consume caffeine?
Yes
No
If yes, approximately how much each day?
Do you consume alcohol?
Yes
No
Do you currently use nicotine or tobacco products?
Yes
No
Do you currently use recreational drugs?
Yes
No
Movement & Exercise
How often do you intentionally exercise?
*
Daily
4-6 times per week
2-3 times per week
Once per week
Less than once per week
Not currently exercising
Which activities do you currently participate in?
Walking
Running
Strength training
Yoga
Pilates
Cycling
Swimming
Dance
Sports
Hiking
Other
What do you enjoy most about movement?
What keeps you from being as active as you'd like?
Stress & Nervous System
What are the biggest sources of stress in your life?
How do you usually cope with stress?
How would you describe your nervous system most days?
Calm and balanced
Often tense or on edge
Frequently overwhelmed
Sometimes shut down or numb
Varies a lot
Other
Do you regularly make time for yourself?
Yes, consistently
Sometimes
Rarely
Not currently
Other
What activities help you feel calm or recharged?
Medical & Safety Considerations
Have you been diagnosed with any medical conditions you feel I should know about?
Please list any prescription medications you currently take.
Please list any vitamins, supplements, herbs, or other wellness products you currently use.
Do you have any food allergies or sensitivities?
Do you have any medication allergies?
Do you have any herbal allergies or sensitivities?
Has your healthcare provider recommended any dietary restrictions or medical treatment plan that should be considered?
Are you currently pregnant, breastfeeding, or planning to become pregnant?
No
Pregnant
Breastfeeding
Planning to become pregnant
Not applicable
Prefer not to say
Focus Areas & Challenges
Which areas would you most like help with?
*
Weight management
Energy and fatigue
Stress management
Sleep quality
Nutrition habits
Exercise consistency
Digestion and gut health
Hormonal balance
Pain management
Mood and mental well-being
Other
What do you believe is the biggest obstacle standing between you and better health?
*
What have you already tried to improve your health?
What worked well?
What didn't work?
Daily Life & Habits
Describe a typical weekday
Describe a typical weekend
What healthy habits are you already doing consistently?
Communication & Follow-Up
If clarification is needed before I create your Blueprint, how would you prefer I contact you?
*
Email
Phone
Best Email
example@example.com
Best Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best Days & Times to Reach You
Would you be interested in scheduling optional Blueprint Reviews every 8–12 weeks to evaluate your progress and update your recommendations?
Yes
No
Maybe later
Agreement & Signature
Agreement acknowledgment
*
I agree to the terms and statements in this intake form
Electronic Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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