Age: AGES 13-25 AGES 26-35 AGES 36-45 AGES 46-60 AGES 61+

Gender Identification: Male Female Other

The date of my last physical was: Within the last 6 months Within the last year One year ago, or more It’s been years!

BMI:

Please use the link below to calculate your BMI and then enter it in the field above.

BMI Link <18.5 18.5–24.9 25–29.9 BMI of 30 or greater

Please select true or false for the following statement: I have a health problem, illness, disease, diagnosis or negative symptoms or concerns True False

Please select true or false for the following statement: I need more support around healthy living and lifestyle True False

Please select true or false for the following statement: I struggle with my emotions, mindset and thoughts True False

Please select true or false for the following statement: I need a health and wellness overhaul and am seeking a complete life transformation True False

Please select true or false for the following statement: I am not exercising enough, or I am not exercising properly True False

Please select true or false for the following statement: I am not eating a balanced diet, or I am not clear on what is a healthy nutrition plan for my body and life True False

Please select true or false for the following statement: I have been diagnosed with anxiety and/or depression or am experiencing anxiety and/or depression True False

Please select true or false for the following statement I feel like having new skills to cope with my emotions and thought patterns would benefit me True False

Please select true or false for the following statement: I feel overwhelmed with stress or have a lot of stressful things in my life right now True False

Please select true or false for the following statement: I have experienced trauma or traumatic events in the past True False

Please select true or false for the following statement: My life feels out of balance in multiple areas and or I am going through a big transition in my life True False

Please select true or false for the following statement: All of my meals are balanced with fresh fruits, vegetables, protein, healthy fats and healthy carbohydrates True False

Please select true or false for the following statement: I often eat too much or not enough True False

Please select true or false for the following statement: I DO NOT have a good relationship with food True False

I DO NOT drink at least 64 ounces of water per day (1/2 gallon) True False

I DO NOT have a regular self-care practice that includes caring for my mind, body, heart and spirit True False

How many of the following things are you currently experiencing or how many of these statements are true:

1. I feel confused about how to create a healthy balanced life
2. I have a chronic illness or disease that impacts my life & health
3. I am unaware how to increase my health and wellbeing effectively
4. I do not take consistent actions to increase my health and well-being
5. I usually do not actively seek out additional ways to get more tools, resources & information to live a healthier life
6. I need support from a number of different types of experts to solve my health & wellness problems
7. I need a complete life transformation
8. I often can’t deal with life and feel like staying in bed
9. I feel low energy frequently
10. I know I could be healthier
11. I am at least 10 pounds overweight
12. I have a chronic illness, disease or injury
13. I do not have enough energy
14. My eating habits are poor
15. I struggle with negative emotions
16. I do not have a consistent exercise routine
17. I constantly feel stressed out or out of balance
18. I feel good but know there is always room for improvement
19. I am not happy with my life
20. I experience poor health

0 1-5 6-10 11-19 20 or more negative things that aren’t listed

How many of the following things are you currently experiencing or how many of these statements are true: When you experience stress, negative feelings and/or emotions, what do you typically do to deal with them? What do you do to avoid feeling uncomfortable? How do you escape or process them (please see the list below and select the total number of the ones that applied to you – if none apply, select 0)

1. Overeat
2. Avoid eating
3. Isolate
4. Get angry and explode at people
5. Avoid the conflict
6. Watch TV or movies
7. Surf the internet
8. Shop
9. Drink alcohol
10. Do drugs
11. Avoid my emotions
12. Play video games or online game

0 1-3 4-6 7-9 10 or more (including other negative habits for dealing with stress that are not listed above)

My biggest goals are: In the area of health and wellness In the area of family and relationships In the area of self-development and spirituality In the area of career and finances I have major goals in all of these areas that are equally important to me