1)  Which Wellness areas interest you? (Check all that apply)

Physical Mental Nutritional Social Environmental Financial

2)  How many hours of peaceful sleep do you get daily?

Less than 4 hours          4 to 6 hours             More than 7 hours

3)  How many ounces of pure water do you consume daily?

Don’t Know                    30 to 60 oz.               More than 75 oz.  

Less than 20 oz.           60 to 75 oz.

4)  How often do you exercise?

Never                     1 to 3 days consistently per week
 
Occasionally        4 to 6 days consistently per week
 
5)  Are you exposed to at least 30 minutes of sunlight daily?

YES           NO

6)  Do you consume a minimum of 5 servings of fruits and vegetables daily?

YES          NO

7)  Rate: Your self-confidence and self-esteem (0 – 10)

0 to 2 Very Low              6 to 8 Average
 
3 to 5 Low                       9 to 10 High
 
8)  Financial Wellness: How many months of expenses do you currently have saved?

0 to 1 Month                    3 to 6 Months                 12+ Months
 
2 to 3 Months                  6 to 12 Months
 
9)  Have you found and are you living your Passion?

YES         NO

10)  What percentage of your relationships are POSITIVE?
(Take your time to think about this one)

Less than 20%                 50 to 75%

20 to 50%                         75% +

11)  How often do you SAY “NO”?

Never           Rarely           Usually          Sometimes           Always
 
12)  Are you working? If so, do you enjoy your current job?

YES       NO
 
13) Do you use Social Media to communicate and stay connected
(Facebook, Twitter, LinkedIn, etc.)

YES      NO
 
14) Please confirm your details:

Email:
 
First Name:            

Last Name:           

Height:             

Your Age:              

Your Current Weight:

Your Goal Weight:

Gender:    Male      Female
 
Zip Code: