Be Well Mindset Interest Form
This survey will be used to help tailor a curricular package to best suit your wellness needs.
How do you feel when you wake up in the morning? Check all that apply
Need More Sleep
Hours of Sleep
How many hours of sleep do you get on average per day?
Less than 5 hours
More than 9 hours
Academic (complete only if in school)
Would you describe yourself as a good student?
**ALWAYS - I love to get high scores YES
**USUALLY - School is a priority MOSTLY
**DEPENDS - if the subject interests me OCCASIONALLY
**SOMETIMES - School is not my priority NO
On Average, how frequently do you get sick and miss school/or work?
7 or less times per year
Once a month
Twice a month
Once per week
Multiple Days per week
Are you comfortable at your current weight? Use the answer that best describes your current feelings.
Most of the time
Yes, but I would like to be healthier
No, I would like to be healthier
No, but I don't care about my weight
No. I'm not sure how to get to my desired weight.
List vegetables you typically eat
Dark Green Leafy vegetables (Spinach, Kale, Collard Greens, Swiss Chard
Root vegetables (carrots, beets, turnips, raddish)
Cruciferous vegetables (Broccoli, Cabbage, Cauliflower, Brussels Sprouts)
Lettuce (Iceberg, Romaine, Oakleaf, Mizuna)
Nightshade vegetables( Potatoes, Tomatoes, Peppers, Eggplant)
List all the fruits you typically eat
Citrus Fruits (Oranges, Grapefruit, Lemon, Limes)
Vining Fruits (Grapes, Passion Fruit)
Melon (Watermelon, Cantaloupe, Honeydew)
Berries (Strawberries, Raspberries, Blueberries, Blackberries, Huckleberries)
What would you like the most support with as you work to obtain more optimal wellness?
What are your areas of stregth that will support you as you work to obtain more optimal wellness?
I will contact you by email to set up a phone call about how the Be Well Mindset can support your needs. If you would like me to call you directly to set this up, please include your phone number here.
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