Wellness Survey - Michael Wollman

Michael's Health Starting Point

Just wait...a few weeks with me, yes, just weeks and this will all change!
Tell me your Full Name

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Today's Date
Address*
City*
State*
Zip Code*
Phone Number*
Date of Birth

MonthDayYear
Date
Right now, how would you describe your overall health? Physical, mental, energy, self confidence...*

0/330
Describe where you would like to be in your Health...*

0/330
Please describe WHY you want to lose weight. (What is your main Motivation...relationships, activities, how you feel, etc.)*

0/330
When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)?*

0/330
Are You...

PregnantNursingPre MenopausePost Menopause
Do you have the following

Type 1 DiabetesType 2 DiabetiesHigh Blood PressureGoutHigh CholesterolHeart ConditionsOther
Are there any food or other allergies that I should be aware of?

0/160
Are you taking other medications or have other medical conditions that could influence which program we choose?*

0/185
Please rate the quality of your sleep
Which of the following do you drink daily?

WaterCoffeeSodaTeaAlcohol
How would you rate your energy level? (on a scale of 1-10)
What, if any, physical activities do you participate in?
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
Are there other stressors in your life?
How many meals per day do you eat?
If you're a snacker, what do you eat?
How often do you eat out each week?
What places do you eat out most?
Current Weight
Goal Weight
Height
On a scale of 1-10 (10 meaning ready to go!), how motivated are you to start working on your health goals?
What has been most difficult about losing/maintaining weight in the past?*

0/200
Would an additional stream of income be beneficial for your family? It was for ours. If you would like to know more about this, let me know.
Is there anyone in your life who would like to get healthy with you?
Thank you for your thoughful and honest answers regarding your current habits. Habit building is the key to long term success. I appreciate you taking the time to complete this form and would love to chat with you further to recommend which program would be the best fit for you. Let's schedule a time!
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Michael's Health Starting Point