Wellness Assesment
A Few Details...
Name
First Name
Last Name
Age
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Describe why you've reached out for assistance
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Exercise Stuff
Do you exercise? How many times per week?
0
1-3
4 or more
Specify type
yoga
dance
weight training
biking
running
walking
sports
Other
If Other, please describe
Where do you workout and what type of equipment do youhave access to?
What type of exercise do you most enjoy?
What type of exercise do you least enjoy?
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Medical Stuff
Please tell about current injuries or chronic pain
Are you currently under a doctor or medical professional's care?
yes
no
none of your BEEZWAX
List medications that may affect ability to exert yourself
Do you smoke/ use tobacco?
yes
socially
smokeless tobacco
no
If so, how many years?
How much per day?
Do you drink? How many drinks per week?
0
1-3
4-6
As much as I damn well please
Do you use sunscreen daily?
yes
sometimes
only as I see fit
sunscreen is for weenies
Age
Submit
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Nutrition
How many cups of coffee or caffeinated beverages do you normally consume daily?
0
1-3
4-6
A whole bunch
How many 8 oz. glasses of water do you normally drink daily?
0-2
3-6
6-8
9 or more
Are you getting 3-5 servings of fruits and vegetables/day?
yes
sometimes
occasionally
never
Do you usually:
Eat out
Cook at home
Both
Wouldyou say your diet is balanced
yes
no
Please describe your current diet
Do you have any food allergies, sensitivities or food you dislike?
What foods do you love or are you partial to?
Do you use vitamins and or supplements (ie. protein, pre-workout, creatine etc)
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Stress, Sleep, and Leisure
How often do you feel stressed?
All of the time
Most of the time
Some of the time
Rarely
Never
What do you consider the main source of your stress?
Work
Family/Friends
Medical
Financial
Relationship Issues/Status
N/A
Other
What activities do you do for fun or relaxation and how many times/week?
Meditation
Deep Breathing
Art/Music
Cooking
Writing
Reading
Travel
Volunteer work
Other
Have you ever sought help to manage your stress
yes
no
If so, Did it help?
yes
Somewhat
no
Do you feel that you've aged due to chronic stress?
yes
No
In the past month, how often have you:
Had trouble sleeping?
All of the time
Most of the time
Some of the time
Rarely
Never
Woke up earlier than desired?
All of the time
Most of the time
Some of the time
Rarely
Never
Felt tired during the day?
All of the time
Most of the time
Some of the time
Rarely
Never
Please share any other information that you would consider pertinent to help you succeed...
Should be Empty: