Align360™ Wellness Readiness Form

This questionnaire helps us understand your wellness goals and background.

Takes about 2 minutes.

First Name

Last Name

Phone

SECTION 1 — MEANING OF WELLNESS

What does “being well” mean to you? Select up to 3.

Energy & focus

Mobility & strength

Longevity & healthy aging

Pain relief

Stress reduction

Better sleep

Mental clarity

SECTION 2 — LIFE STAGE

Which stage of life describes you?

Student / Athlete

Young Professional

Pregnant / New Parent

Mid-Life Adult

Active Senior

SECTION 3 — BARRIERS TO PROGRESS

What currently limits you from achieving your wellness goals? Select up to 2.

Lack of time

Pain or injury

Stress or overwhelm

Low energy or fatigue

Motivation

Financial constraints

Lack of knowledge

Other

If other:

SECTION 4 — COMMITTMENT LEVEL

On a scale of 1–10, how committed are you to improving your health right now?

1 — Not committed

2 — Very low commitment

3 — Low commitment

4 — Somewhat committed

5 — Moderately committed

6 — Above-average commitment

7 — Committed

8 — Highly committed

9 — Very highly committed

10 — Fully committed

Thank you for completing the Align360 Wellness Assessment Readiness Form

The Align360™ Wellness Assessment and all related forms are for educational wellness purposes only and do not constitute medical advice, diagnosis, or treatment. Robinson Chiropractic and Wellness Center does not provide medical services. Please consult a licensed medical physician before beginning any supplement, IV therapy, or other health-related program.