Free Wellness Assessment Questionnaire

Name (first & last):       

Email:           

Weight:         Height:         Age:       

Body Fat Percentage:       

Have you been diagnosed with or experienced any health problems (i.e., high blood pressure, high cholestrol, diabetes, heart attack, stroke, cancer, celiac disease, osteoporosis, etc.)?
yes  no

Are you taking any medications and/or supplements? yes  no
If so, what and why?

What is your energy level? high  normal  low

Do you exercise? yes  no
If so, how often and what activity?

Describe a typical day of eating:
  Breakfast:           
  Lunch:           
  Dinner:           
  Snacks:           
  Beverages/Fluids:           

How often do you eat out?           

Do you have any problems with emotional eating, stress eating, binge eating, or any other food related issues? yes  no

If so, please explain?

Additional comments: