Name
Email
Phone
Age
HEALTH AND WELLNESS GOALS Q1: What are your main health and wellness goals? (e.g., weight loss, improved fitness, stress reduction, better nutrition)
HEALTH AND WELLNESS GOALS Q2: Why are these goals important to you? (Understanding your "why")
LIFESTYLE ASSESSMENT Q1: How often do you engage in physical activity? (e.g., daily, weekly, rarely)
LIFESTYLE ASSESSMENT Q2: What types of physical activities do you enjoy? (e.g., walking, running, yoga, sports)
LIFESTYLE ASSESSMENT Q3: How long do your physical activity sessions usually last?
LIFESTYLE ASSESSMENT Q4: How would you describe your current eating habits? (e.g., balanced, high in processed foods, irregular)
LIFESTYLE ASSESSMENT Q5: How often do you eat fruits and vegetables?
LIFESTYLE ASSESSMENT Q6: Do you have any dietary restrictions or preferences? (e.g., vegetarian, gluten-free)
LIFESTYLE ASSESSMENT Q7: How often do you feel stressed or anxious? (e.g., daily, weekly, rarely)
LIFESTYLE ASSESSMENT Q8: Do you practice any relaxation or mindfulness techniques? (e.g., meditation, deep breathing)
LIFESTYLE ASSESSMENT Q9: How would you rate your overall mental well-being? (1-10 scale)
LIFESTYLE ASSESSMENT Q10: How many hours of sleep do you typically get each night?
LIFESTYLE ASSESSMENT Q11: Do you have a regular sleep schedule? (e.g., consistent bedtime and wake-up time)
LIFESTYLE ASSESSMENT Q12: Do you experience any sleep disturbances? (e.g., insomnia, sleep apnea)
BARRIERS AND CHALLENGES Q1: What obstacles do you face in maintaining a healthy lifestyle? (e.g., lack of time, lack of motivation, financial constraints)
BARRIERS AND CHALLENGES Q2: Have you tried to overcome these barriers in the past? If so, what strategies did you use, and were they successful?
SELF-AWARENESS AND REFLECTION Q1: How well do you understand your body’s needs and signals? (e.g., hunger, fatigue, stress)
SELF-AWARENESS AND REFLECTION Q2: How do you typically respond to challenges or setbacks in your health journey?
SELF-AWARENESS AND REFLECTION Q3: What are your strengths in maintaining a healthy lifestyle? (e.g., discipline, knowledge, support system)
ACTION PLAN Q1: Based on your current lifestyle and goals, what small, manageable changes can you start with? (e.g., drinking more water, taking short walks)
ACTION PLAN Q2: How will you track your progress? (e.g., journal, app, regular check-ins)
ACTION PLAN Q3: Who can support you in your health and wellness journey? (e.g., friends, family, professionals)
ACTION PLAN Q4: How will you seek support when needed?
ACTION PLAN Q5: How will you evaluate the effectiveness of your action plan? (e.g., regular reviews, feedback)
ACTION PLAN Q6: What will you do if you encounter setbacks? (e.g., reassess goals, seek help)
ANSWER YES OR NO: I commit to making small, consistent changes to improve my health and well-being.
ANSWER YES OR NO: I understand that true health is a marathon, not a sprint, and I am dedicated to the principles of Simplicity Focused, Achievable Focused, and Self-Aware Focused.
Additional Information
