Wellness Evaluation

Wellness Check In

Tell us about you so we can build the right plan. Required fields are marked with *.

First name *

Last name *

Contact Number *

Email Address *

Height *

Weight *

6Who sent you this form? *

Goals & Motivation

7What are your long term health & wellness goals? (e.g. kilograms lost, energy, re-shaping, etc)

8What is your main motivation to create and follow through on these changes to your health?

9How serious are you about making these changes? (0 unmotivated → 10 100% committed) *

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Nutrition Habits

10Do you eat 3 meals per day? If not, which meals do you skip? What does your typical day look like?

11Breakfast — Time | Food | Liquid *

12AM Snack — Time | Food | Liquid *

13Lunch — Time | Food | Liquid *

14PM Snack — Time | Food | Liquid *

15Dinner — Time | Food | Liquid *

16Dessert/Snack — Time | Food | Liquid *

17How many times during the week do you eat out? *

18How much water do you drink throughout the day? *

19How much caffeine do you consume on average throughout the day? Do you consume any after 3pm?

Energy, Sleep & Cravings

20Do you experience a drop in your energy levels at a specific time of the day? *

21Do you experience any sugar cravings in the afternoon or evening? *

22How many hours per night (on average) do you sleep? Is your bedtime the same every evening? What is the quality of your sleep like? Do you wake up feeling refreshed?

Stress & Routine

23What would you say on a 0-10 scale your stress levels would be? (0 relaxed → 10 extremely stressed) *

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24Would you like some helpful tips to manage your stress? *

YesNo

25What does your typical evening routine look like? *

Exercise

26Do you currently exercise? What type do you enjoy? How frequently? Are you seeing progress?

Past Efforts

27What have you tried in the past? Did you achieve short term success? Why didn't it work long-term?

Medical Information

28Do you have any known allergies? *

29Are you currently on any medication under the care of a GP? *