Wellness Assessment
Name
First
Last
Email
Phone
I am happy with my energy levels.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I crave carbs and/or sweets
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I drink more than 2 cups of coffee a day to survive.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I have a hard time thinking clearly/have brain fog.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I eat lots of whole foods and feel like I have a healthy diet.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
My menstrual cycle is irregular or causes lots of PMS symptoms for me.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I struggle with depression and/or anxiety
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Tell me about your family life.
*
What do you wish you could do that you can't do now?
*
If you had a magic wand, what would you fix about your health and life first?
*
How would your (and your kids') life be better if that happened? How would that make you feel?
*