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Wellness Self Assessment
Is a wellness program right for you? Take this self assessment to learn more.
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1
Gender
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Male
Female
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2
Age
years
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3
How are you feeling today?
*
This field is required.
Please indicate all of your symptoms.
Sleep Disturbance
Fatigue
Weight Gain
Concentration Deficit
Reduction in libido
Bloating
Hot Flashes
Decreased motivation
Irregular periods
Heartburn
High Blood Pressure
Erectile Dysfunction
Skin Rashes
Incontinence
Headaches
Painful intercourse
Vaginal Dryness
Joint/Back pain
Heart Palpitations
Irritability
Crying Spells
Depression
Burning upon urination
Decreased sexual activity
Hair loss
Chronic pain
Blurred vision
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4
What's the activity level at your job?
none (seated only)
Moderate (light activity such as walking)
High (heavy labor, very active)
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5
Are you experiencing any stresses or motivational problems right now?
Yes
No
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6
Your current diet could be best characterized as:
low-fat
low-carb
high-protein
Vegetarian/Vegan
No special diet
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7
What are your health goals?
Weight loss
Improved overall health
Fat loss
Improved endurance
Increased strength
Increased muscle mass
Increased energy
Improved focus
Better sleep
Increased metabolism
Less reliance on medication
Increased libido
Lower blood pressure
Appetite control
Wake up feeling more rested
Reduced mood swings
Eliminate hot flashes
Eliminate joint pain
Eliminate muscle stiffness
Improve flexibility
Eliminate body pain
Recover from an injury
Other
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8
Do you lack the energy to initiate your plan?
Yes
No
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9
Are you ready to change the way you feel?
Yes
No
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10
Please rate your readiness for change.
1
2
3
4
5
6
7
8
9
10
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11
Do you feel lack of support at times?
Yes
No
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12
Have you been on a doctor guided wellness program before?
Yes
No
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13
We want to know on a "happy scale" how you are feeling.
*
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Please slide the emoji bar to indicate your answers
Quality of Sleep
Energy Level
Mood
Overall Health
Skin Health
Ability to Focus on a Task
Irritability
Discomfort or Pain
Stomach/GI Issues
Weight
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Energy Level
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Skin Health
Ability to Focus on a Task
Irritability
Discomfort or Pain
Stomach/GI Issues
Weight
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14
Full Name
*
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First Name
Last Name
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15
Email
*
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example@example.com
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16
Phone Number
*
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Area Code
Phone Number
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17
Your preferred method of communication
*
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Phone
Email
Text
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