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Your Wellness Profile
Welcome new client. Thank you for answering these questions to help us best serve your needs.
Your Name *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Physical Address
Your answer
Date of Birth
Please include year
Your answer
How many days per week are you able to work out in a gym or at home for 30 to 60 minutes? *
How many days per week would you be willing and able to go for an indoor or outdoor walk for 15- 30 minutes? *
Do you have a set work schedule that allows you to plan your active time in advance? *
How likely are you to stick with a set exercise schedule done on your own at home? *
Highly Unlikely
Will Definitely Do
How likely are you to stick with a set exercise schedule done on your own at a gym? *
Highly Unlikely
Will Definitely Do
Do you currently have a gym membership? *
When was the last time that you felt like the amount of physical activity you were doing was just right?
Hint- Your body gives you clues such as a good energy level, positive disposition and healthy body weight.
Your answer
What time of day do you feel you have the most energy? *
How would you describe your mood most days? *
When doing routine activities such as walking, cleaning, climbing stairs, and shopping, how would you say your stamina is? *
1 =Low, 5 =Above Average
Low
Above Average
How often do you engage in activities to help focus the mind such as meditation or keeping a journal of your thoughts? *
If you are not already doing so, would you be willing to meditate and or journal daily? *
What types of written goal plans do you have? *
Please check all that apply:
Required
How likely are you to use written goals to help you design the life you desire? *
Highly Unlikely
Definitely Willing
Do you believe that prayer, meditation, or journaling your thoughts will help you achieve your goals? *
How likely are you to do the following activities? Please check all that apply *
Required
What type of weight bearing/resistance exercises do you currently do? *
(Please check all that apply)
Required
Do you have any of the following in your home? *
(Please check all that apply)
Required
How would you describe your body? *
(Check All That Apply)
Required
Do you currently have an electronic device that tracks steps, activities or calorie burned such as a fitbit or jawbone? *
How likely would you be to use an online program such as myfitnesspal.com or a smartphone application to track your meals and activity? *
How often do you plan your meals in advance? *
Never
Always
Do you make a list when you grocery shop? *
Which best describes your diet? *
How many caffeinated beverages do you drink per day? *
None
Three or more
Do any of the following apply? *
(Check all that apply)
Required
Do you drink alcoholic beverages? *
How many hours of sleep do you usually get? *
Do you drink enough water daily? *
I tend to be: *
Do you have any food allergies? *
If yes, please describe your food allergies.
Your answer
Do you like to cook? *
Which best describes your relationships with others? *
I attend parties and other social gatherings: *
Your Home Status *
(optional)
How many hours per day do you watch TV? *
Do you currently smoke? *
If you currently smoke, when do you plan to quit?
Please share specifics of plans you've tried in the past and what you plan to do to stop smoking.
Your answer
How many hours do you spend on social networks such as FaceBook, Twitter, Instagram, Pintrest...? *
What are your biggest challenges when it comes to making healthy diet, exercise and lifestyle choices? *
Your answer
What else would you like to share about your wellness goals, personality and preferences?
Your answer
What do you love most about yourself?
Your answer
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