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"A journey of a thousand miles begins with a single step" Lao Tzu
Welcome. Please allow approximately 15-20 minutes to complete the following questions. If you really do not know what to say - please leave the answer blank. Don't overthink your answers.
We are committed to supporting you in getting the results you want in terms of your health and wellness.
The following information will help both of us gain insight that will inform our deep dive conversation.
All information will be kept confidential and will be used exclusively as a reference for us to support you.
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Email
*
Your email
Name
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Birthdate
MM
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DD
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YYYY
Referred by
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Marital Status
Single
Married
It's Complicated
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Primary address
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Secondary address
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Children?
0
1
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3
4
To Be Discussed
In one sentence, please describe what inspired you to seek support around your wellness.
Your answer
What do you hope your wellness plan will give you?
Your answer
Please rate your satisfaction with your health (1=Not satisfied at all 10=Very Satisfied)
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High
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Please rate your satisfaction with your overall energy
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High
Clear selection
Please rate your satisfaction with your overall fitness
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High
Clear selection
Please rate your satisfaction with your sleep habits
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High
Clear selection
Please rate your satisfaction with your connections with loved ones
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High
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Please rate your satisfaction with your community involvement
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High
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Please rate your satisfaction with your eating habits
Low
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High
Clear selection
Please rate your satisfaction with your career
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High
Clear selection
Please rate your satisfaction with your hobbies/leisure
Low
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High
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Please rate your satisfaction with your downtime
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High
Clear selection
Please rate your satisfaction with your sense of purpose/meaning/spirituality
Low
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High
Clear selection
Please rate you average level of stress on a scale of 1-10 (0=no stress, 10=extremely stressed)
Low
1
2
3
4
5
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7
8
9
10
High
Clear selection
Have you experienced any recent trauma or hardships? If so, please explain.
Your answer
Occupation
Your answer
Check the 3 that are most important to you:
career achievement
financial success
longevity
family
travel
spirituality / faith
community
friendship
fitness
creativity
energy / vitality
beauty
health and wellness
Other:
What are your wellness objectives? (check all that apply)
decrease stress
improve sleep
reduce pain
prepare for an event
lose weight
support pregnancy or postpartum
improve strength
improve flexibility and mobility
improve stamina/endurance
mental performance - creativity, focus, etc
support grieving process
Other:
What obstacles have you faced that have impeded your ability to engage in self care (i.e., exercise, meditation, healthy eating)? (check all that apply)
Applies
time
medical
cost
fear
travel
commitment
orthopedic pain
motivation
other
Applies
time
medical
cost
fear
travel
commitment
orthopedic pain
motivation
other
Clear selection
How many hours (on average) do you sleep/night?
Your answer
Is your sleep schedule consistent?
Your answer
Do you sleep continuously through the night? If not, how many times do you wake up?
Your answer
Typically, what time do you fall asleep, what time do you wake up?
Your answer
How many days/month do you travel for work?
0-4
5-10
11+
Other:
Clear selection
How many days/month do you travel for pleasure?
0-4
5-10
11+
Other:
Clear selection
On average, how many vacation days do you take/year?
0-10
11-24
25+
Other:
Clear selection
Do you follow a specific diet?
Yes
No
Maybe
Other:
Clear selection
Do you prefer to eat alone or with others?
Your answer
Have you tried any specific diets in the past? If so, please list what you have tried.
Your answer
How often do you drink alcoholic beverages?
Your answer
How often do you use recreational drugs?
Your answer
Do you have concerns about your weight?
Your answer
Have you ever participated in sports? Y/N If yes, list the sport, level (recreational, club, varsity, college, semi or pro) and years of play:
Your answer
What fitness/wellness activities do you currently participate in, and with what frequency?
Your answer
What fitness/wellness activities have you done in the past that you have NOT enjoyed?
Your answer
What fitness/wellness activities have you done in the past that you HAVE enjoyed?
Your answer
Do you currently have a stillness practice (i.e. meditation, mindfulness, prayer, etc.)? Have you had one in the past? If so, please describe.
Your answer
Which of the following are you interested in learning more about?
Flow/Ashtanga
Yin
Restorative
Bikram
Yoga Tune Up
Other
Yoga
Flow/Ashtanga
Yin
Restorative
Bikram
Yoga Tune Up
Other
Yoga
Mixed Movement
HIIT
Weight Training
Resisitance Bands
Other
Personal Training
HIIT
Weight Training
Resisitance Bands
Other
Personal Training
Stillness Practices
Zen
Transcendental
Yoga Nidra
Mindfulness
Mantra
Tibetan
Chakra
Meditation
Zen
Transcendental
Yoga Nidra
Mindfulness
Mantra
Tibetan
Chakra
Meditation
Touch
Thai Massage
Reiki
Assisted Stretch
Massage
Thai Massage
Reiki
Assisted Stretch
Massage
Community
Volunteering
Community gardening
Theater
Art therapy
Recreational sports
Engagement
Volunteering
Community gardening
Theater
Art therapy
Recreational sports
Engagement
Is there anything else you would like to share with your wellness advisor at this time?
Your answer
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