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Health Assessments
Wellness Checkup
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Take this
Wellness
Checkup and
receive
feedback directly from me
1. What’s your name?
2. What is your email address?
3. What area of your health are you most concerned with or would you most like to improve?
4. What medical condition have you been diagnosed with by a physican (e.g., high blood pressure, diabetes, high cholesterol, or cancer)?
5. I mostly feel:
Full of energy
Could use more enegry at times
Sluggish at times
Often fatigued
6. My bowels are:
Choose option from dropdown
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7. My digestion is:
Crampy after eating
Bloated and gassy
Heartburn
No concerns
8. I consume alcohol or wine:
Daily
Weekly
On occasion
I don't drink
9. I crave:
Mostly sweet foods (candy, cake or ice cream)
Mostly sweet drinks (soda, fruit juices or tea/coffee)
Mostly salty foods (chips, fries or fried foods)
I do not have cravings often
10. My sleep is:
7 to 8 hours of rested sleep (no interruptions)
5 to 6 hours (often interrupted)
3 to 4 hours (way up mid-way cannot return to sleep)
Suffer from insomnia (take sleep medication regularly)
Submit Wellness Checkup
