Wellness Evaluation Form

Health Status

what is your current weight?

what is your current age?

Do you have any medical conditions?

what is your current height?

Are you currently taking any medications?

Nutrition and Diet

what is your typical daily diet like? Ominvore, Vegetarian, Vegan, Etc

Do you take any supplements or vitamins?

What are your favorite foods?

How many meals do you typically eat a day?

Lifestyle and Habits

How often do you exercise per week?

What type of exercise do you typically do?

How many hours of sleep do you get per night?

Do you smoke or consume excessive alcohol?

Goals and Motivations

What are your top three wellness goals?

What motivates you to make healthy changes?

Is there any additional information you'd like to share about your health and wellness?

Contact Information

Full Name

Email *

Date of birth

Phone *

Thank you for taking the time to complete this wellness evaluation form. By doing so, you'll be providing valuable information to help better understand your health and wellness needs and provide

personalized guidance and support.