Wellness Assessment Form

- General Information -

completed_wellness_form

First Name

Last Name

Email

Password

Phone

Emergency Contact

Age

Gender

Height

Weight

Date of Birth

Martial Status

Number of pregnancies

Number of children

Ages of children

Name of partner or spouse?

Occupation

Retired?

Yes

No

Date of retirement

Disability?

Yes

No

Date of disability

Who is your primary care doctor:

Phone Number of primary care doctor:

Who referred you? How did you find us?

-Health-

How would you rate your general health?

Excellent

Good

Fair

Poor

Please list your medications/suppliments

Allergic to any medications?

Yes

No

Please list medication allergies

Please list any Hospitalizations/Operations/Medical Procedures and Approximate Dates

Do you have any health concerns?

Have there been any recent changes in your health or weight? When did the changes start?

Do you exercise regularly? Please list what type of exercise, how often per week, and for how many minutes.

-Sleep and Energy-

What is your energy level like in the morning when you wake up and then throughout the day? Do you notice an energy drop and time of day that it occurs?

Sleep Issues? Do you have any problems falling asleep or staying asleep? How often do you wake up and when?

Do you feel rested when you awake?

How much sleep do you normally get?

Do you have sleep apnea? Do you snore at night? Do you use a CPAP?

-Food, Diet, Habits-

Do you have any food allergies or sensitivities?

Any dietary preferences/restrictions?

Do you have any food cravings?

Do you smoke or use tobacco products?

Yes

No

How many years did you smoke or use tobacco?

If you quit, when did you stop smoking or using tobacco?

Do you drink alcohol?

Yes

No

How many drinks per month?

Do you drink coffee?

Yes

No

How much coffee per week?

Amount of sugar intake per day?

-Sample of typical day’s menu for you-

Breakfast:

Lunch:

Dinner:

Snacks in between:

-Stresses-

How would you rate your stress level for the following areas in your life? (Please rate from 0 to 10, with 10 being extremely stressful)

How well do you handle stress? What do you do to help relief yourself of stress?

Have there been any recent changes in your stress level?

What is your source of strength and hope?

What gives you inspiration?

What are you passionate about?

Is there anything you would like to change in your life if you could?

Is there anything you would like to change within you, or that you would like to work on or learn?

What are your goals, dreams, aspirations, if all obstacles were removed?

Do you feel you make good use of your time?

Are you organized or do you often feel overwhelmed?

What brings you here?

Are you seeing any doctors, health practitioners, or counselors for any of the mental/health issues mentioned above?

Is there any health related issues or information we should know about that was NOT mentioned above?

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Wellness Assessment Form