Your Wellness Survey

YOU'VE NEVER HAD THIS DAY BEFORE!!

With Rob & Jenn McDuffie
Date

MonthDayYear
Date
Name

First NameLast Name
E-mail
example@example.com
Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
BEST PHONE NUMBER WHERE YOU CAN BE REACHED
Format: (000) 000-0000.
Best Day/Time to Call at Above # (OPTION 1)

MonthDayYear
Date
Hour MinutesAM/PM Option
Best Day/Time to Call at Above # (OPTION 2)

MonthDayYear
Date
Hour MinutesAM/PM Option
Best Day/Time to Call at Above # (OPTION 3)

MonthDayYear
Date
Hour MinutesAM/PM Option
Date of birth

MonthDayYear
Date
How Did You Hear About Us
If Referred,
If Other
WHAT IS YOUR WHY
I WANT TO LOSE WEIGHT BECAUSE...
CURRENT REALITY

WHERE ARE YOU NOW?
CURRENT WEIGHT
GOAL WEIGHT
HAVE YOU TRIED TO LOSE WEIGHT BEFORE?
WHAT PROGRAMS HAVE YOU TRIED? DID ANY OF THEM WORK?
MEDICAL
ARE YOU PREGNANT
ARE YOU NURSING
DO YOU HAVE ANY OF THE FOLLOWING
IF OTHER, PLEASE EXPLAIN
ARE YOU TAKING ANY MEDICATIONS FOR :
PLEASE LIST ALL MEDICATIONS TAKEN (IF NONE TYPE NA)
IS THERE ANYTHING ELSE WE SHOULD KNOW ABOUT YOUR HEALTH (IF NO TYPE NA)
SLEEP
HOW MUCH SLEEP DO YOU GET PER NIGHT
HOW IS YOUR QUALITY OF SLEEP
MOTION

EXERCISE IS NOT REQUIRED TO DO THIS PROGRAM, BUT WE DO HAVE PROGRAMS FOR THOSE WHO EXERCISE. EXERCISE WILL COME LATER, ONCE YOU HAVE REACHED A HEALTHY WEIGHT
HOW ACTIVE ARE YOU
HOW MANY HOURS A DAY DO YOU SIT
HOW MANY DAYS A WEEK DO YOU EXERCISE
WHAT PHYSICAL ACTIVITIES DO YOU ENJOY OR WOULD LIKE TO ENJOY, ONCE YOU REACH A HEALTHY WEIGHT
FOOD & HYDRATION
HOW MANY MEALS & SNACKS DO YOU EAT A DAY(CHECK ALL THAT APPLY)
HOW MANY TIMES A WEEK DO YOU EAT OUT
HOW MANY OUNCES OF WATER DO YOU DRINK PER DAY
WHAT OTHER BEVERAGES DO YOU DRINK
IF OTHER
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YOU'VE NEVER HAD THIS DAY BEFORE!!

CURRENT REALITY

MEDICAL

SLEEP

MOTION

FOOD & HYDRATION

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