Wellness Assessment

How many hours of sleep do you get in a typical night?

How many 8oz glasses of water do you drink a day on average?

Check the beverages you have on a daily basis.

How would you rate your energy level?

Do you exercise to stay active? If so, what types of exercise do you do?

How many hours a week do you consider yourself physical active (include exercise and other activity)

Please check the option that best describes the activity level of your job.

Do you have any physical restrictions or limitations that affect your ability to stay active? If so, please describe below:

Fow would you rate your stress level?

What are the sources of your stress?

How would you describe your diet? Select the option that is most applicable.

Do you wish to make changes to your diet? If so, why?

List any allergies below.

Do you have any health issues? If so, please describe below:

Please list anything else that is necessary to evaluate your current state of wellness.

I, the undersigned, understand that this consultation is not a substitute for medical attention, examination, diagnosis or treatment and may not recommended and or considered safe under certain medical conditions. I should consult a physician prior to beginning any wellness program. I recognize that it is my responsibility to notify Balance 2 Heal of pregnancy, any serious illness, and/or injury before proceeding. I affirm that I alone am responsible to decide on my wellness. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Balance 2 Heal or Eliza Alys Young. Those under 18 years of age must have this form signed by a parent or guardian.

I confirm that I have read and agree to the Terms & Conditions.