Wellness History & Goals Questionnaire
We focus on uncovering root causes for lasting breakthroughs—not temporary fixes. This quick history & goals questionnaire is simply the best way for us to understand your unique situation and prepare meaningful options to help you thrive.
Date Form Submitted
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Month
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Day
Year
Date
Name
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First Name
Last Name
USA Phone Number
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Format: (000) 000-0000.
Phone Number (Only If out of USA)
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Country Code
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Area Code
Phone Number
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
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Day
Year
Date
Age
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Gender
Male
Female
We conduct periodic follow-ups as part of our full client service. Select preferred contact methods; all that apply.
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Text
Cell Phone
Email
Other
How can we support your wellness goals? (Select all that apply.)
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Chronic Pain Relief
Recovery from an Injury
Recovery From a Surgery
Optimize Athletic Performance
Improve My Overall Posture
Specific body Imbalances, pigeon toes, flat feet, scoliosis, etc
Reduce Chances of Future Injuries
Stress Reduction
Improve Energy
Trauma Release
Other
How did you hear about us? (Google search, referral; specify referrer for thanks.)
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If Google search: What terms did you use?
We offer online Zoom coaching for pain relief, nutrition, and in-home personal training. (Select all that apply.)
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I prefer in-office sessions for my sessions.
Prefer in-office sessions, but travel often; open to learning about online benefits.
I live out of the area; open to explore online training program options.
In pain? If yes, rate 1-10 (10=worst). Duration of pain/limitations from injury/condition?
How would life be better without this pain or limiting condition? Is it limiting you from doing or enjoying things you want to do?
Your Activity Level: How would you describe yourself?
Pro or semi-pro athlete
Serious recreational athlete
Youth athlete in school sports
Moderately active
Not Very Active But Looking to Start
Not Active and Not Interested In Changing
Do you participate in sports or competitive activities? If team-based, what position do you play?
On a scale of (1-10, 10=laser sharp) how's your mental edge lately?
On a scale of (1-10, 10=high) how's your overall energy during training or at work lately?
Timeline: How soon ready for your tailored 97% success program? —your timing helps us plan real breakthroughs.
Ready Now, the sooner the better!
In the next 2-4 weeks.
Within 1-3 months.
Not sure yet—let's talk options first
Occupation
Height
Current Weight
Weight 1 year ago
Ideal Weight
Family History: Mother's age and health status.
Father's age and health status.
Personal History: Any serious illnesses/hospitalizations/surgeries/limitations? (Please list the dates or your age the time the event took place):
Is using a natural approach to wellness important to you?
What treatments have you tried? Please select all that apply.
Surgery
Physical Therapy (PT)
Chiropractic
Rolfing
Massage
Reiki, or other Energy Work
Acupuncture
Cranial Sacral Therapy
Hypnosis
Meditation
Egoscue Method
Alexander Technique
Nutritionist/Health Coach
Hyperbaric Treatments (HBOT)
Other
What supplements/vitamins do you currently take?
Any known allergies/sensitivities? Are you taking medications for them?
Digestion: (Check if You Experiencing Any On A Regular Basis)
Irritable Bowel Syndrom (IBS)
GERD, Gastro Esophageal Reflux Disease
Burping, Gas, Bloating
Heartburn or Sour Stomach
Constipation
Diarrhea
Bowel Movement Frequency? (helps link gut health/dietary inflammation to pain)
1 time per day
2-3 times per day
A few times per week.
Once a week or less.
History of any of the following conditions?
Chronic Fatigue
Sleep Apnea
Allergies/ Seasonal or Food
Asthma/COPD/ Other Respiratory Challenges
Arthritis, Fibromyalgia
Scoliosis
Osteoperosis
Stress or Nervousness
High or Low Blood Pressure
Heart Condition
Cancer
Diabetes
Parkinson's
MS/Multiple Sclerosis
Epilepsy
Phlebitis
PTSD or any trauma history
Other
Quick Safety Note: To keep our sessions safe and enjoyable for both of us (no treatments here—just prevention), please share if any of these apply. Totally optional and confidential—your comfort comes first.
Cold, Flu, Aches & Pains, Unusual Recent Fatigue
Herpes, Shingles, Chicken pox
Hepatitis A,B or C
HIV, AIDS
Staff Infection, MRSA
Tuberculosis, TB
Recent COVID-19 or history of Long COVID
Any lasting effects from COVID Vaccination or Boosters
EBV, Epstein Barr Virus, past or present
Please elaborate on any yes answers to the history of conditions above.
What prescription medications do you currently take?
When Is the last time you were on an antibiotic? Name of antibiotic?
Ever on antibiotics ≥3 months? Condition? Antibiotic name?
Are you on hormone replacement therapy (HRT)?
Hormone Replacement Therapy?
What time do you normally go to sleep? What time do you normally wake up?
Do you wake up at night? How often? Why (e.g., pain, bathroom)?
Do you feel rested when you wake up?
Yes, I almost always feel great when I wake up.
Sometimes I feel rested when I wake up.
I feel pretty good once I have my coffee.
I am usually still very tired when I wake up.
Would you like to sleep better?
Yes, I would like to sleep better.
I sleep good so it is not really a concern of mine.
What kinds of things do you like to do to help you relax?
For Woman/Reproductive History
Next 7 questions:
Are you Pregnant?
Yes
No
Are Your periods regular?
Painful or Symptomatic?
Have you had children? Ages?
Reaching or approaching menopause?
Any abdominal surgeries (C-section, lipo)? If yes, ongoing side effects?
Nutrition Information
Fill out nutrition section even for pain relief: Food impacts inflammation, pain, and healing speed.
What do you like to eat for breakfast?
What do you like to eat for lunch?
What do you like to eat for dinner?
Snacks
Weekly beverage intake: How much water & other drinks (e.g., coffee, soda) do you consume?
Cravings: Do you crave sugar, coffee, chocolate, cigarettes, or other? (List any.)
Currently on a diet or nutrition program? (Yes/No; details if yes.)
Ever kept a food journal or diary? (Yes/No)
What % of your meals are home-cooked?
Sources for other meals? (e.g., restaurants, delivery, pre-made)
Own any of these kitchen tools? (Blender, juicer, etc.—select all that apply.)
Blender
Juicer
Vitamix, Nutribullet, Nija
Rice Cooker
Crock Pot
Instantpot
What 1-3 health habits do you know you "should" do—but haven't yet? (We're here to help make 'em stick!)
Our 12-Session Align & Heal Program has a 97% success rate, fueled by constant improvements. If you join, open to sharing end-of-program feedback?
Yes, I am open to sharing feedback.
Yes, however, my privacy is very important, so only anonymously, my name must be kept private.
Thank you but I would prefer to not to offer feedback.
Comfortable with us sharing your progress on social media? (Yes/No; details if yes.)
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Yes, I use social medial and would consider showcasing my before and after transformation on social media!
No thank you, I prefer my privacy and don't get involved in social media.
Other
Anything else to share that could boost your outcomes? (We're all ears!)
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