Client Health and Well-Being Assessment

Please note that all client information will be kept confidential and will only be shared with your written consent.  This submitted form is sent only to my private email address on a secure server.

Name *
Name
Address *
Address
Please check if you have had any of the following: *
Please check if TRUE for you: *
How often, on a typical workday, do you feel rested, energetic, and able to perform at your best? *
How often, when you are NOT working, do you feel rested, energetic, and able to perform at your best? *
Do you have dificulty falling asleep or staying asleep? *
How many hours of sleep do you get on the average weeknight (M-F)? *
How many hours of sleep do you typically get on a weekend night (Sat/Sun)? *
You experience the following energy boosters in your life (please check all that apply): *
You experience the following energy drains in your life (please check all that apply): *
In the past month, have you accomplished LESS than you would like in your work or other daily activities due to low energy or lack of focus? *
In the past month, has your energy level interfered with normal social activities with family and friends? *
How would you rate your readiness to make changes or improvements in your energy level? *
How often do you feel calm and peaceful? *
How often do you take the time to relax and have fun daily? *
How often do you feel anxious or stressed? *
How often do you feel overwhelmed or out of control? *
How often do you feel frustrated, impatient, or angry? *
You have suffered a personal loss or misfortune in the past year (for example, death of someone close to you, a separation or divorce, a job loss, etc.) *
How would you rate your readiness to make changes or improvements in your stress level? *
Is your appetite usually (check one): *
Has your appetite changed noticeably in the last year? *
Have you experienced significant unexpected weight gain or loss in the last year? *
How often do you eat a full breakfast? *
How often do you typically eat at least 5 servings of vegetables and fruits? *
How often do you eat dessert or snack on pastries, cake, ice cream, cookies between meals? *
How often do you drink alcohol? *
How would you rate your readiness to make changes or improvements in your nutrition: *
How often do you engage in moderate or vigorous physical activity for at least 30 minutes? *
Which physical activities do you engage in regularly (choose all that apply)? *
How would you rate your readiness to make changes or improvements in your physical activity levels?
You feel deep satisfaction or joy in your life *
You feel grateful and appreciative for what you have *
You are satisfied with your job *
You feel optimistic about the future *
You feel like your time is well-balanced between work, family, friends, and self *
One area you would like to have more time for is *
How would you rate your readiness to make changes or improvements in your life satisfaction or life balance? *