Wellness Assessment Form

WELCOME!

Please complete the following questions to help us understand your health background, lifestyle, and goals. Fields marked with an asterisk (*) are required.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

CityState

Zip CodeCountry

Date of Birth

Date

Age:

Starting Weight

Goal Weight

Relationship Status:

Occupation:

Hours Worked per Week:

Other

If children, list their ages:

Any animals/pets?

Wellness Concerns Questionnaire

What are your main health concerns that you would like to work on?

Do you have any other concerns or symptoms?

What are your main health and wellness goals? Select all that apply.

At what point in your life did you feel your best?

Please provide details of your medical history, including any previous surgeries.

What is or was your parents’ health like? Please provide details for both your mother and father.

Did you experience any digestive issues as a child?

What is your heritage?

What is your blood type? (if known)

How would you describe your current sleep quality?

How many hours of sleep do you usually get each night?

Do you experience any pain, stiffness, or swelling?

Are your bowel movements regular? Do you experience bloating, diarrhoea, constipation, or gas?

Do you have any allergies or sensitivities? Please provide details.

Women's Health

Are your periods regular?

Have you reached menopause, or are you currently experiencing perimenopause? Please provide details. (Add N/A if Not applicable.)

Please provide details of your contraceptive history, if applicable. (Add N/A if Not applicable.)

Do you experience yeast infections/urinary tract infection? Please explain.

Medical Information

Are you currently taking any medications or supplements? Please list them below.

Are you currently working with any healthcare practitioners or receiving any therapies or treatments? Please provide details.

How would you describe your current level of physical activity?

Food Information

What do you typically eat for breakfast, lunch, dinner, and snacks?

How often do you consume alcoholic beverages?

Do you experience any cravings or habits you would like support with?

Do you cook?

How often do you dine out at restaurants? Select the option that best describes your usual habits.

How do you typically spend your downtime? Please select the option that best describes your usual activities:

Is there anything else you would like us to know?

ProGutCare Client Disclosure and Agreement

Welcome to ProGutCare. Before we begin your journey to optimal health, we kindly ask you to review and acknowledge the following disclosures and agreements:

General InformationProGutCare is a wellness program designed to support and improve gut health through holistic methods, including dietary guidance, lifestyle changes, and detoxification protocols. While we aim to enhance overall wellbeing, ProGutCare is not intended to diagnose, treat, cure, or prevent any disease.

Client ResponsibilityMedical Advice: ProGutCare does not replace medical advice from licensed healthcare professionals. It is recommended that you consult your doctor before starting any new wellness program, especially if you have pre-existing medical conditions, are pregnant, or are on prescribed medication.
Compliance: Success in this program requires adherence to the guidance and protocols provided. Results may vary based on individual commitment and effort.
Privacy and ConfidentialityAll client information will be kept strictly confidential and used only for program-related purposes.
ProGutCare will not share your personal information without your explicit consent unless required by law.
By signing this agreement, you acknowledge that you have read, understood, and agree to the terms outlined above.

Do you acknowledge that you have read, understood, and agree to the terms outlined above.

Other

Social Media Consent: Do you consent to the use of your images, testimonials, or progress updates for ProGutCare’s social media and promotional purposes?

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