Wellness Survey

Get the assistance you need for a healthier life,
complete the Wellness Survey below to start your journey!

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Wellness Survey

* Indicates required field

Name *

First

Last

Email *

Today's Date *

Address *

City *

State *

Zip *

Phone Number *

Date of Birth *

How did you hear about our program? *

Preferred Method of Contact *

Describe where you are in your Health now... (Weigh, sleep, stress, energy, etc.) *

Descrie whre you would like to be in your Health... *

Please describe WHY you are interested in getting healthy. (Whate is your main Motivation... relationships, activities, how you feel, etc.) *

When was the last time you remember feeling your best in your health or being at your ideal weight or size (if that's part of your goal)? *

Are you Pregnant? *

Are you Nursing? *

Do you have the following... Diabetes-Type 2, High Blood Pressure *

Are there any food or other allergies that I should be aware of? *

Are you taking any medication for: High Blood Pressure, High Cholesterol, Thyroid** ) *

Are you taking other medications or have other medical conditions that could influence which program we choose? *

How many hours of sleep do you typically get? *

What time do you typically go to bed? *

What time do you wake up feeling rested? *

How much water do you drink each day? *

How much coffee? *

How much soda? *

How much Tea? *

How much Alcohol? *

How would you rate your energy level? (on a scale of 1-10) *

How many times a week do you exercise? *

What physical activities do you participant in? *

Are there things you can't do that you would like to be able to? *

How would you rate your stress level? (on a scale of 1-10) *

What do you do for work? *

How much do you enjoy what you do? *

Are there other stressors in your life? *

How many meals per day do you eat? *

When do you eat your first meals? *

When do you eat your last meal? *

Do you snack between meals? *

How many times a week do you eat out? *

Where? *

Current Weight *

Goal Weight *

Height *

How healthy would you rate your surroundings? (on a scale of 1-10) *

Do you have healthy & active friends, supportive family? *

Do you keep junk food in the house, etc? *

Is there anyone in your life who would like to get healthy with you? *

Comment *

Submit

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Copyright 2008. All rights reserved. She Builds a Vineyard (Trademark). Founded by Dr. Willie Mae Hawkins, author. She Builds a Vineyard(TM): A Mentoring Program for Women and Teenage Girls is a program of Community Ministries, Inc. a 501(c)3 tax-exempt organization. The program was initiated from Dr. Hawkins' doctoral project from Regent University. Website produced and maintained by M&R Publishing, LLC.