Your Health and Wellness Assessment Name * First Name Last Name Email * Wellness check in - On a scale from 1 to 10, 10 being excellent, how would you rate your overall health and why? * What are your primary health goals? (What outcome do you want to achieve?) * Use this space to tell me about your health goals. What is your current height and weight? * If comfortable, please tell me what is your age? Thinking about your physical health which includes physical illness and injury, how many days during the past 30 days was your physical health not good? * Thinking about your mental health, which includes stress, depression, and problems with emotions, how many days during the past 30 days was your mental health not good? * During the past 30 days, about how many days did poor physical or mental health keep you from doing usual activities, such as self-care, school, work, recreation or family time? * Do you currently take any medications? If so, for how long and name them below. What is your vision for working with a health educator? * Which area of focus are you most interested in? * Losing weight Increasing energy Detoxing/Cleansing Chakra Alignment Plant Medicine Spirituality Yoga Movement Mental Health Relationships Meditation If there are more than one area that interests you, please list them below. Do you have any chronic or pre-existing health conditions? * Do you feel supported in your daily life by family, friends or employer? * Tell me what a typical meal looks like for you? * How many meals do you cook in a week? * How often do you eat take out/ delivery? * How many glasses of water do you drink a daily? * How many fruits do you eat in a daily? Name them below. * How many vegetables do you eat in a daily? Name them below. * How much exercise do you do daily? Name the exercise and the duration. * Do you smoke cigarettes? * Yes No How has the current state of the country affected your mental, physical, and spiritual well-being? * Wellness check out - On a scale from 1 to 10, 10 being most committed, how would you rate your current level of commitment to transitioning to a healthy lifestyle and why? Is there anything else you would like me to know? Thank you!
