Skip to content
Wellness Evaluation
Wellness Evaluation
*
1.
First and Last name/ preferred method of contact
(Required.)
*
2.
What are your wellness goals? (Weight loss, muscle gain, energy, focus)
(Required.)
3.
What wellness programs/ products have you used in the past?
*
4.
What do you typically eat in a day?
(Required.)
*
5.
What is your daily water intake?
(Required.)
*
6.
What do you drink?
(Tea, soda, coffee, alcohol, energy drinks)
(Required.)
7.
How many days a week do you eat out/ what is the average cost/ meal?
*
8.
Where is your energy level 1-10
(Required.)
9.
Do you experience fatigue?
*
10.
What is your sleep schedule?
(Required.)