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Wellness Assessment
STEP 1 — GOALS & BACKGROUND
What are your primary wellness goals?
More energy
Better sleep
Reduce stress
Reduce pain or inflammation
Improve mental clarity
Balance hormones
Improve digestion
Prevent disease
Which areas concern you most?
Energy
Sleep
Stress
Pain
Brain fog
Hormones
Immune health
What motivates you?
Longevity
Daily well-being
Productivity
Prevent illness
Physical performance
How would you rate your health?
Excellent
Good
Fair
Poor
Age range
Under 25
25–34
35–44
45–54
55–64
65+
Gender
Female
Male
Prefer not to say
Do you follow a wellness plan?
Yes
No
STEP 2 — ENERGY
Which energy challenges apply?
Chronic fatigue
Afternoon crashes
Low motivation
Difficulty waking
Exhaustion after activity
When do you feel most tired?
Morning
Afternoon
Evening
All day
Which apply?
Depend on caffeine
Energy fluctuates
Consistently low energy
Stable energy
After sleep you feel:
Refreshed
Somewhat rested
Still tired
Stamina level
Low
Moderate
High
Energy crashes
Daily
Weekly
Rare
Motivation
Rarely
Sometimes
Usually
STEP 3 — SLEEP (ROOT CAUSE)
Sleep challenges
Difficulty falling asleep
Waking during the night
Waking too early
Restless sleep
Light sleep
Poor recovery
Sleep duration
<5 hrs
5–6
7–8
9+
What affects your sleep?
Racing thoughts
Stress/anxiety
Environment
Screen time
Daytime sleepiness
Frequent
Sometimes
Rare
What wakes you up?
Pain
Need to reposition
Racing thoughts
Unknown
How your body feels at night
Relaxed
Tense
Restless
Uncomfortable
Temperature issues
Too hot
Too cold
Fluctuates
No issue
Restlessness patterns
Toss and turn
Wake frequently
Can’t get comfortable
Overall sleep
Deep
Light
Inconsistent
Poor
STEP 4 — STRESS, ENVIRONMENT & FINANCIAL
Stress symptoms
Overwhelmed
Anxiety
Irritability
Burnout
Trouble relaxing
Stress frequency
Constant
Frequent
Occasional
Rare
Stress effects
Affects sleep
Causes fatigue
Causes headaches
Affects digestion
Stress resilience
Poor
Moderate
Strong
Family/home environment
Very supportive
Somewhat supportive
Neutral
Somewhat stressful
Very stressful
Support system
Fully supported
Somewhat supported
Not supported
Work environment
Supportive
Neutral
Stressful
Work stress level
Low
Moderate
High
Extreme
Work-life balance
Excellent
Good
Fair
Poor
Time for self-care
Yes
Sometimes
Rarely
Never
Financial stress level
Very stable
Moderate stress
High stress
Severe stress
Does money stress affect you?
Yes significantly
Somewhat
Rarely
Not at all
STEP 5 — PAIN & INFLAMMATION
Do you suffer from any of these?
Joint pain
Muscle pain
Back pain
Headaches
Chronic inflammation
How often do you have pain?
Daily
Weekly
Occasional
Rare
Does pain cause any of these issues?)
Morning stiffness
Pain with movement
Limits activity
How often do you get swelling?
Frequent
Occasional
Rare
How long does it take your body to recover after exercise?
Slow
Moderate
Fast
How is your inflammation level?
Inflammation present
Sometimes
No
Does pain affect any of these?
Pain disrupts sleep
Sometimes
No
STEP 6 — BRAIN FUNCTION
Does any of these affect you?
Brain fog
Poor focus
Forgetfulness
Mental fatigue
How often are you affected by this?
Daily
Weekly
Occasional
Rare
Do you have problems with any of these?
Trouble concentrating
Memory issues
Mental slowness
How is your focus level?
Excellent
Good
Fair
Poor
How is your mental clarity?
Sharp
Moderate
Low
Does this affect you?
Mental fatigue
Sometimes
Rare
STEP 7 — CIRCULATION & DETOX
Does any of these issues affect you?
Cold hands/feet
Tingling
Swelling
Slow healing
Do you get bruises?
Bruise easily
Sometimes
No
Are you exposed to any of these toxins?
Plastics
Pesticides
Air
Chemicals
How often do you eat processed foods?
Daily
Weekly
Rare
Do you use any of these to help your body detox from the environment?
Exercise
Sauna
Clean diet
None
What type of water do you drink?
Filtered
Mixed
Tap
How often do you sweat?
Sweat regularly
Sometimes
Rare
STEP 8 — MEDICAL HISTORY
Do you suffer from any of these conditions?
Autoimmune
Thyroid
Hormonal imbalance
Diabetes
Heart disease
Cancer
Other
👉 Text Field: List conditions
Do you have a family history of any of these conditions above?
Yes
No
Unsure
Do you take medications?
Yes
No
👉 Text Field: List medications
Are you under the care of a provider currently?
Yes
No
Do you frequently get ill?
Yes
Sometimes
Rare
Do you have digestive issues?
Yes
Sometimes
No
Have you had any major health events?
Yes
No
👉 Text Field: Describe
STEP 9 — SUPPLEMENTS & LIFESTYLE
Do you take supplements
Yes
No
👉 Text Field: List supplements
What types of supplements do you take?
Vitamins
Minerals
Herbs
Plant extracts
Protein
Amino acids
Probiotics
Detox
Hormone support
Other
👉 Text Field: Other supplements
How long have you taken supplements for?
<1 month
1–3
3–6
6–12
1+ yr
How effective are your supplements?
Significant
Some
None
Unsure
How is your experience using supplements?
Many supplements no results
Some results
Routine works
Unsure
How often do you exercise?
Daily
Weekly
Rare
How is your diet?
Excellent
Good
Fair
Poor
How often do you eat produce?
Daily
Weekly
Rare
What is your hydration level?
High
Moderate
Low
How often do you consume alcohol?
None
Occasional
Moderate
Frequent
How often do you smoke or vape
No
Occasional
Daily
How long have you smoked or vaped?
<1 yr
1–5
5–10
10+
How much do you use?
Light
Moderate
Heavy
How often do you drink soft drinks?
None
Occasional
Weekly
Daily
What types of beverages do you consume?
Regular soda
Diet soda
Energy drinks
Sugary coffee
Juice
STEP 10 — HEALTHCARE & READINESS
Are you concerned about your healthcare costs?
Yes
Somewhat
No
Are you interested in affordable healthcare?
Yes
Maybe
No
Does telehealth interest you?
Yes
Maybe
No
Are you interested in holistic care services?
Massage
Chiropractic
Naturopath
Yoga
None
Do you prefer more guidance?
Yes
Maybe
Not now
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Founder · Retired Family Nurse Practitioner
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