Health and Wellness Form

Name
First Last
Date
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
How did you hear about my services?
STEP ONE What Is Your Current “Health Blueprint”?
On a scale of 0-10, (0 = ‘I’m a train wreck’); (10 = ‘I feel so good I can’t stand it’) how would you rate your health now?*
Please enter a number from 1 to 10.
Using the same scale of 0-10, listed above, how would you rate your life now?*
Please enter a number from 1 to 10.
What is your #1 health complaint?
How long have you had this issue?
What have you done to heal this issue?
What were your results?
What has someone suggested you do for this condition that you have resisted doing or procrastinated doing?
If you could make a guess of what or who could help you with this issue, who or what would that be?
Please fill in all the blanks that describe your health practices
When I start ____________ , I run out of motivation and go back to previous habits that are familiar, but don’t help me. For example, when I start exercising, my work schedule changes and I miss days of exercise.
I put off starting ________________ , even though I know it would help my health.
List three health habits that you have started, that you believe will help your health at this time:
List three habits you would like to eliminate at this time that you believe hurt your overall health:
List the three persons, places or things that support your health in order of importance:
List three persons, places or things that you believe hinder your health at this time:
What do you imagine will happen in 5 years if you don’t make positive changes regarding your health now?
Are you ok with that? If not, Why?
How do you cope with stress in everyday life? (please check all that apply):
- exercise
- relaxation
- alcohol, cigarettes or drugs
- hobbies & recreation
- family activities
- other
Who do you have in your life that encourages and supports you?
What makes NOW the perfect time to take more control over our health and life?
If NOW is not the best time, what would need to happen to make this a top priority for you?
STEP TWO Your Key Frustrations & Concerns
The following checklists are designed to identify your key frustrations and concerns, and the systems. Please check all that apply
#1 - Physical Concerns
- I experience daily muscle and/or joint pain
- I am usually tired throughout the day.
- I’m too tired to exercise regularly at least 3x a week.
- I take at least 1 medically prescribed medication daily.
- I crave processed foods, corn and foods made with white sugar and flour.
- I experience daily digestive symptoms: gas, bloating, diarrhea, constipation.
- I rarely sleep 7-8 hours at night without waking at least once.
- I have a medically diagnosed disease.
- I am overweight or obese.
- I get sick frequently with colds and flu.
#2 - Emotional Concerns
- I experience sadness and anger many times a day.
- I have been diagnosed with a mental disease.
- I feel like I lead a very stressful life.
- I feel alone and without social support.
- My relationships are often difficult and contain a lot of conflict.
- I feel unmotivated and have few goals in life
- I feel irritable most days and many things annoy me.
- I feel my life is out of balance.
- I put other people’s needs ahead of my own most of the time.
- I don’t feel I am living up to my potential.
#3 - Psycho-Spiritual Concerns
- My life has no real purpose to me
- I have never explored my inner world.
- I have no religious or spiritual affiliations.
- I don’t have exciting things to look forward to.
- I am afraid of exploring my inner world.
- I have never had a spiritual experience
- I don’t remember my dreams and when I do, I never reflect on them or their meaning
- Life is nasty and then we die.
- I don’t believe there is an afterlife
- I don’t feel fulfilled by life.

Fill out a quick Health and Wellness Questionnaire.

Get a Free 20 Minute Consultation.

Start the Questionnaire!

(734)453-2207

EwBorg@WellnessEvolutions.com

Health and Wellness Form

Health and Wellness Form

STEP ONE What Is Your Current “Health Blueprint”?

Please fill in all the blanks that describe your health practices

STEP TWO Your Key Frustrations & Concerns

Fill out a quick Health and Wellness Questionnaire.

Get a Free 20 Minute Consultation.