Free Wellness Survey
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Email Address
*
example@example.com
Contact Number
*
How did you hear about me?
Preferred Method of Contact
Text
Call
Email
Lets Talk about YOU!
Describe to me where you are in your health now. this can include weight, nutrition, sleep, stress, and energy.
Where would you like to be in your health?
Describe WHY you are interested in getting healthy. what is your main motivation? Relationships, activities, how you look or feel?
When is the last time you remember feeling your best in your health or being at an ideal weight/size?
Lets talk about your background
Do you have any of the following
Diabetes - Type 1
Diabetes - Type 2
High Blood Pressure
Gout
Are you taking any medication for:
Diabeties
High blood pressure
High Cholesterol
Thyroid
Lithium
Coumadin (Warfarin)
Are there any dietary restrictions you currently utilize? Please specify if you have a diagnosed food allergy.
*
Are you taking any other medications or have any other medical conditions that could influence the program we choose?
*
Lets Talk about Sleep
How many hours of sleep do you normally get?
What time do you generally wake up?
How is your quality of sleep?
Do you wake up feeling rested?
Lets talk HYDRATION
How much water do you drink each day?
How much Coffee?
How much Soda?
How much Tea?
How much Energy Drinks?
How much Alcohol?
Next up Movement and Motion
How would you rate your energy level? (on a scale of 1-10)
How many times a week do you exercise?
What physical Activities do you participate in?
Are there things you cannot do that you would like to be able to do?
Lets talk Head Space
How would you rate your stress level? (on a scale of 1-10)
What do you do for work?
How much do you enjoy what you do?
When and where was your last vacation?
Are there any other stressors in your life?
Tell me about Food
how many meals per day do you eat?
When do you eat your first meal?
When do you eat your last meal?
Do you snack between meals?
what kind of snacks?
How many times a week do you eat out?
Lets talk Weight
Current weight
Height
Goal weight
Have you tried to lose weight before?
What has been the most difficult about losing/maintaining weigh in the past?
Lets talk about your Community
How healthy would you rate your surroundings? (on a scale of 1-10)
do you have healthy & active friends, supportive family,, keep junk food in the house, etc?
is there anyone in your life who would like to get healthy alongside you?
if you have ever before or currently use medically supported weight loss, please describe your experience:
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