Name
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First Name
Last Name
Email
*
Phone
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Gender
Height
Weight
Do you have any current or past medical conditions e.g. diabetes, hypetension, heart disease, asthma etc.
Are you currently taking any medications or supplements. Please list along with dosages.
Do you have any allergies e.g. food, medication, environmental etc.
Have you undergone any surgeries or major medical procedures? If yes, please specify.
Do you have any family history of medical conditions e.g. cancer, diabetes etc.
How many hours of sleep do you typically get each night?
Do you have any sleep-related issues e.g. insomnia, restless legs, frequent waking etc.
Do you have a consistent bedtime routine?
Do you feel rested upon waking?
What is your current family structure e.g. single, married, living with partner,children etc.
How would you describe your relationship with your family? Are there any ongoing conflicts or challenges?
Do you provide care for any family members? If yes, what is the extent of your caregiving responsibilities?
How does your family support your health and wellness goals?
What are the main sources of stress in your life e.g. work, finances, relationships, health concerns etc.
How do you typically cope with stress e.g. exercise, meditation, talking to friends, therapy etc.
On a scale of 1 to 10, how would you rate your current stress levels?
What is your current marital status e.g. single, married, divorced, widowed etc.
If married or in a relationship, how would you describe your relationship?
How does your marital status affect your overall well-being?
What is your current occupation?
How many hours do you typically work in a normal week?
Do you enjoy your work? On a scale of 1 to 10, how satisfied are you with your job?
Do you experience work-related stress? If yes, what are the main contributors?
Are you in a purpose-driven career or job? Do you feel fulfilled by your work?
How often do you engage in physical activity e.g. daily, weekly, rarely etc.
What types of physical activities do you participate in e.g., walking, running, weight training, yoga etc.
How long do your physical activity sessions usually last?
Do you experience any physical limitations or injuries that affect your activity levels?
On a scale of 1 to 10, how would you rate your overall physical fitness?
On a scale of 1 to 10, how happy are you with your life overall?
What aspects of your life bring you the most joy?
Are there areas of your life where you feel unfulfilled or unhappy?
Do you regularly engage in activities or hobbies that bring you joy?
Do you have children? If yes, how many and what are their ages?
How would you describe your relationship with your children?
What challenges do you face as a parent?
How do you balance your parenting responsibilities with your personal health and wellness?
Do you identify with a particular faith or spiritual practice? If yes, please specify.
How important is your faith in your daily life?
Do you engage in regular spiritual practices or attend religious services?
How does your faith influence your health and wellness?
On a scale of 1 to 10, how connected do you feel to your spiritual beliefs?
Have you been diagnosed with any mental health conditions e.g, ADHD, depression, anxiety, bipolar disorder etc.
Do you experience symptoms of depression or anxiety? If yes, how frequently and to what degree?
Do you see a therapist, counselor, or mental health professional?
How do you manage your mental health e.g. medication, therapy, self-care practices etc,
On a scale of 1 to 10, how would you rate your current mental health?
Do you feel that you are living a purpose-driven life? If yes, what is your purpose or mission?
How often do you engage in activities that promote self-development?
How often do you engage in activities that promote self-development e.g. reading, courses, workshops, coaching etc.
What goals or aspirations are you currently working towards?
On a scale of 1 to 10, how committed are you to your personal growth?
Do you have a mentor or guide who supports your self-development journey?
On a scale of 1 to 10, how would you rate your overall wellness?
What areas of your life would you like to improve?
What areas of your life would you like to improve?
Do you have any specific health or wellness goals you are currently working on?
How motivated are you to make changes to your health and wellness?
What resources or support do you feel would help you achieve your wellness goals?
