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est.
2014
Wellness Questionnaire
First Name
Email Address
Last Name
Date of Birth
Nutrition
Do you follow a specific eating style or diet?
No
Yes
If so, please state what and since when?
What is a typical breakfast?
Do you eat lots of greens on a daily basis? If so, elaborate
In the past 3 years how many courses of antibiotics have you been on?
On average, how many fruit juices or frizzy drinks do have a week?
How many caffeinated beverages do you consume daily?
How many times a week do you consume alcohol?
What do you snack on during the day?
How often to you make eating decisions you regret?
Around what time in the evening do you stop eating?
Do you take any supplements?
Yes
No
On average, how much water do you drink a day?
Sleep
On average, how many hours of sleep do you get a night?
How long does it usually take you to fall asleep once in bed?
Add answer here
Choice 1
Choice 2
Choice 3
Choice 4
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If you have any diagnosed health problems list the conditions(s).
Do you have any issues staying asleep through the night?
Yes
No
What time do you usually go to sleep?
How many times a week would you say you have a problem with your sleep?
How would you rate your sleep quality?
Poor
Fair
Good
Very good
Excellent
How would you rate your sleep quality?
How woul you rate your enery levels throughout the day?
Poor
Fair
Good
Very good
Excellent
How woul you rate your enery levels throughout the day?
Do you use any electronic devices while in bed? Phone, laptop, etc.
Yes
No
Stress
On a scale of 1-10 what would you rate your general level of anxiety/stress?
How stressful would you consider your job?
Are there any things you believe you use to distract yourself from, or to conceal your anxiety and stress?
Yes
No
Do you watch, listen to, or read the news on a daily basis?
Yes
No
When was the last time you decluttered your home/living space?
How much time on average, do you spend scrolling on social media?
How often do you feel negative emotions arise out of nowhere?
Never
Sometimes
Often
General Health
How many times a week do you exercise/move with some intensity?
Which kinds(s) of exercise/movements do you do and for how long?
Are you a current cigarette smoker?
Yes
No
If so, how many do you smoke a day?
If you have any injuries, please list them.
If you are on any medications, please list them.
How much time would you be willing to allocate yourself for a morning routine?
How much time would you be willing to allocate yourself for an evening routine?
Please rate your readiness for change
Somewhat ready
Ready and motviated
Not ready
Initials
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