Health and Wellness Questionnaire - Living Vibrantly
Thank you for taking the time to fill out this form! Once I receive your responses I'll create a personalized recommendation just for you. Looking forward to chatting more and hopefully working together! xo, Elizabeth
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Email *
Name *
Tell me a little bit about your life. Do you have kids? Married? Work? Give me a peek into your day-to-day.
What is your reason for being interested in this fitness/nutrition/wellness challenge? What health-related goal(s) would you like to achieve?
What obstacles or challenges are you facing that have held you back from reaching these goals in the past?
Which of these do you definitely LIKE or enjoy, or want to try? Check all that apply.
Which of these do you definitely DISLIKE? Check all that apply.
Do you own free weights or are you willing to purchase them?
Clear selection
Do you have regular access to high-speed Internet at home? (This will help me know whether to recommend a DVD or streaming option for you.)
Do you have any injuries or physical limitations?
Would you say nutrition is a strength or a weakness? Please explain.
Do you struggle with any of the following? Check all that apply.
Explain the previous answer to the extent you feel comfortable doing so.
What (if anything) would you like to change or improve, in terms of your health and how you feel?
Could you use help with any of the following? Check all that apply.
How does your current lifestyle affect the way you feel about yourself and the things you want to do in life? How will it affect you in the next year if nothing changes?
How do you feel when you look in the mirror today, and how do you want to feel?
What else would you like me to know?
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