1. Health and Wellness Form - Wellness Evolutions

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Date

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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

#2 - Emotional Concerns

#3 - Psycho-Spiritual Concerns