Family Wellness Assessment
Use this as a tool to assess your health and the health of your family. Once filled the form will get emailed to the address given in this form. The body of the email will contain your answers and you will also receive a PDF copy.
Email *
Date
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Name
Age
Please list names and ages of all family members
Describe your overall health and well being.
Are there any other specific health issues that you would like us to be aware of?
Do you or any of your family members take supplements and / or medications?
Have you or someone in your family ever done a cleanse / detox before? If so, when and what did it consist of?
Check off all that apply per family member. Please check N/A if family member does not apply.
Allergies to Certain Food
Major Gluten Intolerance
Allergies to Dairy
Allergies to Nuts
Allergies to Certain Grains
Allergies to Plants or Other Greenery
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Check off all that apply per family member. Please check N/A if family member does not apply.
Under Stress
Experience Anxiety
Lack Focus
Other Mental Health Issues
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
What are your health goals this year? Please check N/A if family member does not apply.
Energy
Weight Loss
Cleansing
Focus
Athletic Performance
Behavior
Better Skin, Hair and Nails
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
How is your sleep and that of your family members? Please check N/A if family member does not apply.
Deep Sleep
Moderate
Not Good At All
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Do you experience any digestion issues? Please check N/A if family member does not apply.
Bloating
Elimination Issues
Indigestion, heart burn, burning stomach acids
Gas pain
None
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Are the following items part of you or your family's diet? Please check N/A if family member does not apply.
Meat
Seafood
Dairy
Grains
Gluten
Sugar
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Describe your and your family's daily diet.
Do you or any family member feel sluggish or yucky throughout the day? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Do you or any family member often get food cravings throughout the day? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Are you or any family member often restless or irritable? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Have you or any family member recently experienced unexplained weight gain or loss? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1