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