Wellness Assessment

Please complete the assessment below. When you have finished answering the questions please click submit located at the end of the assessment.

First Name
Last Name
Birth Date
Gender
Relationship Status
Children and ages
Occupation
Address
City
State/Province
Zip
Email
Phone
Indicate coach name if you have already selected your coach

Priorities for Coaching

I want to address the following areas with my coach (check up to five areas)

Overall
Physical


Mental and Environmental



Spiritual

Life Satisfaction

I feel I have a strong reason for being
I feel satisfied with my life
I feel appreciative for what I have in my life
My level of satisfaction at work could be described as
My level of satisfaction in my personal relationships could be described as
My Importance: Rate the importance to me of managing my health: 1-10 (10 highest level)
My Readiness to Change: My readiness to make changes or improvements in managing my health
My Confidence: My confidence level to make changes or improvements in managing my health: 1-10 (10 highest level)

Energy

On a scale of 1-10 (10 being the best energy) how much energy do you feel you have

During a typical work day
When you are not working
What time is your energy level highest during the day
What time is your energy level the lowest during the day
Choose the top 3 things that boost your energy


Choose the top 3 things that drain your energy







My Importance Energy: Rate the importance to me of managing my health: 1-10 (10 highest level)
My Readiness to Change Energy: My readiness to make changes or improvements in managing my health
My Confidence Energy: My confidence level to make changes or improvements in managing my health: 1-10 (10 highest level)

Nutrition

Height (inches)
Current Weight
Weight 5 yrs ago
Weight at 21 yrs old
What is you most preferred weight (in pounds)
My Importance Nutrition: Rate the importance to me of reaching and sustaining a healthy weight: 1-10 (10 highest level)
My Readiness to Change Nutrition: My readiness to make changes or improvements to reach and sustain a healthy weight
My Confidence Nutrition: My confidence level in my ability to reach and sustain a healthy weight: 1-10 (10 highest level)
Please choose from the list below any previous weight management programs or diets you have pursued in the past




Are you on a diet at the present time
If yes, describe what type of diet below
Do you eat every 3-4 hours most days of the week
On average how many fruits do you eat a day
On average how many servings of vegetables do you eat daily
When given the opportunity how often do you choose whole grain products
Do you drink alcoholic beverages
If yes how many drinks per week? Note: One drink = 1 oz. of hard liquor, 4 oz. of wine, 12 oz. of beer
How many ounces of caffeinated beverages do you drink per day
How many ounces of water do you drink per day

How often do you eat high fat or high sugar snacks between meals? (cookies, candy bars, chocolate, pastries, etc.)
How often do you eat foods high in saturated fat? (saturated fat is found in red meat, butter, lard, whole milk dairy products, shortening, fried foods, French fries, pork sausage/bacon, etc.)


Exercise

Are you presently exercising minimum of three times per week for at least (20) minutes at a time?
If yes, what exercises


Total minutes engaged in aerobic activity per week

Total minutes engaged in strength training activity per week

Total minutes engaged in flexibility exercises per week
Do you have any medical conditions for which a physician has ever recommended some restrictions on activity (including injuries, illness, medical conditions, surgery)
If Yes, please explain
My Importance Exercise: Rate the importance to me of managing my health: 1-10 (10 highest level)
My Readiness to Change Exercise: My readiness to make changes or improvements in managing my health

My Confidence Exercise: My confidence level to make changes or improvements in managing my health: 1-10 (10 highest level)

Health Check Up

How would you describe your general health
Systolic Blood Pressure (upper number)
Diastolic Blood Pressure (low number)
Total Cholesterol
HDL (good cholesterol)
LDL (bad cholesterol)
Fasting Triglyceride level
Fasting glucose level
Fasting Hemoglobin A1C (if applicable)
When was your last physical examination

Please check any conditions which are present in your family, of which you are aware

Heart attack
Stroke
Diabetes
High blood pressure
High cholesterol
Colorectal cancer
Breast cancer
Depression
Suicide
Osteoporosis

Personal Health History

Lung disease (asthma, emphysema, other)

Bowel
Cancer
Chronic Obstructive Pulmonary Disease
Coronary heart disease
Depression or any mental illness

Diabetes (Pre Diabetes)

High blood pressure (140/90 or higher)
High blood cholesterol (200 or higher)
Chronic back problem
Stroke  
Arthritis
Women's Health Issues





Men's Health Issues
Gastrointestinal Issues

How much bodily pain have you had during the past month
Health Limitations: During the past four weeks, how much difficultly did you have doing your work or other regular activities as a result of your physical health
How many days did you miss work due to illness or injury in the last 6 months
Medications: Please list all medications
Do you smoke/chew
Have you ever smoked/chewed
How many packs per day
When did you quit
Please list any previous bone/joint injuries or conditions
Please list any significant health/medical conditions (i.e. previous surgeries, current pregnancy, diseases, etc)
My Importance Health: Rate the importance to me of managing my health: 1-10 (10 highest level)
My Readiness to Change Health: My readiness to make changes or improvements in managing my health
My Confidence Health: my confidence level to make changes or improvements in managing my health: 1-10 (10 highest level)

Stress and Mental Health

Indicate how you are dealing with daily stress 1-10 (1 Not Coping Well -10 Coping Well )
How many hours of sleep do you normally get
Check the description that best represents the amount of stress you experience on a daily basis
During the past month, to what extent have your daily activities been affected by emotional issues
(depressed, anxious)
1 - None, 10 - Daily
Social Activity- During the past four weeks, to what extent has your physical health or emotional issues interfered with your normal social activities with family, friends, neighbors, or groups

Personal Loss

Have you suffered a personal loss or misfortune in the past year? (For example: a job loss, disability, divorce, separation or the death of someone close to you)

Social Support

Do you have friends/family with whom you can share problems/get help if needed?

Stress and Mental Health

The next questions are about how you feel things have been with you during the past four weeks.For each question, please give the one answer that comes the closest to the way you have been feeling. How much of the time during the past four weeks...

Have you felt calm and peaceful
Did you have a lot of energy
Have you been a happy person


Did you take the time to relax and have fun daily

Depression Evaluation

For each question, please give the one answer that comes the closest to the way you have been feeling. How much of the time during the past four weeks...

Been feeling low in energy, slowed down

Been blaming yourself for things

Had a poor appetite

Had difficulty falling asleep, staying asleep

Been feeling hopeless about the future
Been feeling blue
Been feeling no interest in things
Had feelings of worthlessness

Thought about or wanted to commit suicide
Had difficulty concentrating or making decisions

My Importance Mental and Emotional Fitness: Rate the importance to me of reaching and sustaining optimal mental and emotional fitness (managing stress and emotions well and maintaining a positive mindset) 1-10 (10 highest level)
My Readiness to Change Mental and Emotional Fitness: My readiness to make changes or improvements to reach and sustain optimal mental and emotional fitness is
My Confidence Mental and Emotional Fitness: My confidence in my ability to reach and sustain optimal mental and emotional fitness (managing stress and emotions well and maintaining a positive mindset) 1-10 (10 highest level)