Wellness Evaluation Form
First Name
*
Last Name
*
Email
*
Main Complaint
*
Any other complaints *
How long have you suffered with this problem? *
Would you like improvement with any of following? *
Digestion: Reflux, Gas, Constipation
Sleep: Falling asleep or staying asleep
Sense of Well Being
Energy
What have you tried doing to resolve this problem that Did Not work? *
Have you become discouraged or stressed about handling this problem? *
When your problem is at its worst, how does it make you feel? *
How does this problem interfere with work? *
How does this problem interfere with family? *
How does this problem interfere with hobbies? *
How does this problem interfere with life? *
Do you know how this problem may have started? *
What effect does this have on your body functions? *
Are you here visiting us to: *
Resolve my immediate problem
Life style program for optimized living
Both
Other
How have you taken care of your health in the past? *
Medications
Routine medical
Exercise
Diet and Nutrition
Holistic
Vitamins
Chiropractic
Other
If you answer is other then explain here
What are you afraid this might be or will be affecting without change? Please circle *
Job
Kids
Marriage
Sleep
Freedom
Future abilities
Finances
Time
How did the previous methods work for you? *
Are there any health conditions you are afraid this might turn into? *
Diminished Future abilities
Stress
Weight gain
Heart disease
Depression
Surgery
Arthritis
Cancer
Diabetes
Other:
If you choice other please explain here
Where do you picture yourself being in the next 3-5 years if this problem is not taken care of? Please be specific *
What would be different or better without this problem? Please check *
Diminished stress
More energy
Self esteem
Confidence
Sleep
Work
Outlook
Family
If we were to sit down and discuss your life 3 years from now and look back at today, what would have to have happened for you to be happy with your progress? (Please take your time and don’t sell yourself short! Include anything that is part of your happiness, whether health, family, work, finances, travel, marriage or bucket list) *
What potential barriers do you foresee that would prevent these things from happening? *
Do you feel it is possible to eliminate or prevent these potential barriers? *
What are your strengths that will enable you to accomplish your goals? *
How important is it for you to resolve your health concerns? * (1 is considered lowest and 10 is considered highest on the scale.)
Do you feel that you are coachable and would enjoy a mentor in helping you? *
Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals? *
Submit