TransforMEtion Journey Wellness Questionnaire
Thank you for taking the time to fill out this short questionnaire to help better assist you with your health & wellness goals. Your answers WILL NOT be shared with any third parties or anyone else without your consent.

✴DISCLAIMER- Coach V (Valencia Williams)  is a Certified Nutrition Coach, with emphasis in Health & Wellness, and  she is NOT a doctor, and DO NOT claim to have ANY medical background credentials. Products and services that will be suggested to you, is not intended to diagnose, treat, cure or prevent any diseases. Always consult your medical provider before committing to any coaching advice, or recommendations.

Coach V- Valencia Williams
Ph: 214.286.4256
Email: transforMEtionjourney@gmail.com 
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Email *
Cell phone number: *
First Name: *
Last Name: *
Mailing Address: *
City: *
State: *
Zipcode: *
Do you consider yourself specially concerned for your health? *
Which, if any, of these ailments do you suffer from? Choose all that apply. *
Required
If you chose "other", please explain here what other ailments. *
Which, if any of these, ailments are you concerned about (either due to family history, lifestyle, previous experience etc)? Choose all that apply. *
Required
On average, how long do you sleep? *
Typically, how often do you workout? *
How long does your typical workout last? *
How active is your lifestyle? *
Do you feel you have emotional support from your friends/relative? *
How often do you attend social gatherings (club meetings, family gatherings, and others)? *
How often do you feel stressed in a typical week? *
How do you manage your stress? *
How healthy would you rate yourself to be? *
Do you eat more than 5-7 servings of fruits and vegetables a day consistently? *
How many healthy meals do you eat during the work week? *
How many servings of protein do you consume per day? *

Diagnosed medical conditions:  

Please Specify Below or enter N/A

 *

Are you currently on medication?

List medications below or answer N/A if you are not on medication.

 *

Do you have any food allergies?

Choose all that apply.

 *
Lactose Intolerance:    ☐Yes     ☐No *

Special Diets: 

 *
Would you be interested in healthy recipe options? *
Would you be interested in a CUSTOMIZED meal prep services tailored towards your health needs? (Dallas, Forth Worth and surrounding areas) Offering contactless deliveries or pick-up *
Do you need  CUSTOMIZED meal plan or meal prep service?


 *
Would you be interested in 1 on 1 coaching ? *
What is your favorite color? *
Who reffered you? *
A copy of your responses will be emailed to the address you provided.
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