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Questionnaire
Patient Information and Consent
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Home
Resources
Articles
Books
Mediterranean Diet
Recipes
Schedule a Session
BMI Calculator
Calorie Counter
Our Team
Blogs
Contact Us
Questionnaire
Patient Information and Consent
Notice of Privacy Practices
Questionnaire
Lifestyle Questionnaire
To be completed before first Wellness Coaching session
Your Name *
(Required)
First
Email
(Required)
WATER
How often do you drink water? *
(Required)
How much water do you drink daily? *
(Required)
How much of it is filtered or purified? *
(Required)
EXERCISE
How often do you exercise? *
(Required)
What types of exercise do you do regularly? *
(Required)
What is your nutritional approach to help your body build lean muscle and recover from your workouts? *
(Required)
STRESS MANAGEMENT
How many hours of sleep do you get daily? *
(Required)
What do you do daily to prevent or reduce stress? *
(Required)
To what extent do you spend time in nature or a use a mindfulness practice for stress management? *
(Required)
TOXICITY
What do you do physically to rid your body of toxins? *
(Required)
What do you do nutritionally to detoxify your body?
(Required)
Nutrition
BREAKFAST
(Required)
What are your three favorite well balanced and nutritious meals? Please be specific.
LUNCH
(Required)
What are your three favorite well balanced and nutritious meals? Please be specific.
DINNER
(Required)
What are your three favorite well balanced and nutritious meals? Please be specific.
SNACKS
(Required)
What are your three favorite well balanced and nutritious snacks?
