Wellness Questionnaire

545-5456331_your-holistic-self-mind-body

Nutrition

Do you follow a specific eating style or diet?
Do you take any supplements?

Sleep

arrow&v
Do you have any issues staying asleep through the night?
How would you rate your sleep quality?PoorFairGoodVery goodExcellent How would you rate your sleep quality?
How woul you rate your enery levels throughout the day?PoorFairGoodVery goodExcellent How woul you rate your enery levels throughout the day?
Do you use any electronic devices while in bed? Phone, laptop, etc.

Stress

Are there any things you believe you use to distract yourself from, or to conceal your anxiety and stress?
Do you watch, listen to, or read the news on a daily basis?
How often do you feel negative emotions arise out of nowhere?

General Health

Are you a current cigarette smoker?
Please rate your readiness for change
Upload File

Thanks for submitting!