Wellness Questionnaire Name * First Name Last Name Email * Phone * Please rate how accurate the below statements are for you personally * Answers will be kept private and confidential. Most days I feel good. Strongly Disagree Disagree Neutral Agree Strongly Agree I am stressed. Strongly Disagree Disagree Neutral Agree Strongly Agree I have many good relationships in my life. Strongly Disagree Disagree Neutral Agree Strongly Agree I sleep well most nights. Strongly Disagree Disagree Neutral Agree Strongly Agree I am well organized. Strongly Disagree Disagree Neutral Agree Strongly Agree Please fill in the blank or choose the letter that most correctly resembles your choice. When I allow myself to get out of balance I usually feel * A) anxious, overwhelmed B) depressed, sluggish, tired C) irritated, angry D) it varies I usually wake up around * A) 6am B) 7am C) 8am D) 9am E) 10am When I wake up * A) I am awake immediately. B) I move slow, it takes time for me to wake up. A perfect dinner for me would be * A) vegan enchiladas B) chicken or fish with local, cooked vegetables C) pasta with meatballs bread and salad D) huge raw salad with lettuces, kale, pumpkin seeds, avocado, shredded beets carrots n walnuts E) Immune boosting soup with shiitake mushrooms, local veggies, onion, garlic, ginger, turmeric For dessert I like * A) Chocolate! B) Something light with in season fruit. C) A nice after dinner drink. D) Ice cream and cake. E) Crème Brule Mostly I crave the ____ taste. * A) Salty B) Sweet C) Sour D) Astringent (Wine) E) Bitter (Black Coffee, Dark Chocolate) F) Pungent (jalepeno, chilis, hot sauce) I have a tendency towards * A) inflammation B) weight gain C) indigestion D) chronic pain E) headaches F) none of the above My health and wellness routine could really benefit by _____. * Have you been sick in the past few months? * Are you unusually tired? * Are you coughing or sneezing? * Is there anything else you think I should know? Thank you for taking the time to fill this out. Thank you!
