Tell Me About You

Wellness Form

Help me understand your current health and wellness by completing this form. It will remain anonymous and will be used only to help me guide you on your wellness journey.

Contact Information
Name
First Last
Age
Email
Phone
Skype handle
Your Wellness and Health Assessment
Height
Current Weight
Would you like your weight to be different?
Relationship status
Children? If so, how many?
Occupation and number of hours worked per week
Are you overwhelmed or frequently stressed out?
List your main wellness goals and concerns
Any serious illness/surgeries/hospitalizations recently?
What were your wellness challenges as a child or early adult?
Do you sleep well? How many hours per night?
Do you wake up at night? If yes, why?
Do you experience pain, stiffness, or swelling?
Do you experience constipation, diarrhea, or gas?
Do you have difficulty with digestion and daily elimination?
Do you take supplements or medications?
Do you exercise? And if yes, how often?
What do you eat for breakfast, lunch, and dinner?
How often do you drink water? How much?
Do you consume alcohol? How often? How much?
Do you consume caffeine? How often? What time? How much?
Will your family and friends be supportive of eating and lifestyle changes? List any challenges
Do you cook?
The most important thing I should do to change my health and wellness is:
Comments
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By mail:

For The Health of It ~ 10559 Millbrook Rd. Blanchard, MI 49310

By phone: 989-621-5580

By email: alisonsuemiller@gmail.com

Wellness Form

Contact Information

Your Wellness and Health Assessment