Wellness Questionnaire

I want to address the following areas with my coach:

□ Improved energy
□ Increase physical activity
□ Lose weight

□ Maintain weight
□ Improve eating habits
□ Improve health risks or medical conditions

□ Reduce need for medication
□ Improve sleep
□ Manage stress better or reduce stress
□ Improve life/work/school balance

How often are you physically active each week? (continuously moving your body for 15+ minutes)
□ 6-7 times per week
□ 4-5 times per week

□ 2-3 times per week
□ 1 or fewer times per week

How often do you eat breakfast each week?

□ Every day
□ Most mornings
□ 2-3 times per week

□ Almost never

How many 8 ounce glasses of water do you drink a day?

□ 6 or more glasses
□ 4-5 glasses
□ 1-3 glasses

□ None

FRUITS AND VEGETABLES:

How may servings of fruits and vegetables do you eat daily? (A serving is: 1 cup fresh, 1/2 cup cooked, 1 medium fruit, or 3/4 cup juice)
□ One or less

□ Two daily
□ Three daily
□ Four daily
□ Five or more daily

How many 8 ounce portions of a soft drink do you drink each day?

□ None or rarely
□ 1-2 portions
□ 3-5 portions

□ 6 or more portions

How often do you eat “junk” snack foods between meals? (Ex. pastries, candy, ice cream, cookies)

□  Three or more times per day

□  Once or twice per day

□ A few times per week

□ Seldom or never

How many hours of sleep do you get on average?

□ Less than 6 hours
□ 6-7 hours
□ 7-8 hours

□ 8 or more hours

Do you have any limitations in exercising? (arthritis, back injury, sprained ankle, etc.)
□ No
□ Yes

Questions, comments or concerns for my Coach