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WELLNESS QUESTIONNAIRE

First name

Last Name

Average Water Consumption in a Day

Average Amount of Sleep Per Night

Average # of Days/Week You Workout

Amount of Time for Average Workout

Any Injuries/Medical Conditions I Should Be Aware of?

Are You Taking Any Medications/Supplements (List All)

Average # of Days/Week You Eat Out

Less than 2

3-4

More than 5

Rate Current Support System

Exellent

Good

Okay

Poor

Rate Current Energy Levels:

High

Medium

Low

Average Daily Caffeine (Cups) Intake

Less than 2

3-4

5-6

More Than 7

Average Alcohol Conumption/Week

Less than 2

3-4

5-6

More Than 7

Anwer the Following Statements (On Average):

I Eat Breakfast

YES

NO

I Eat a Mid-Morning Snack

YES

NO

I Eat Lunch

YES

NO

I Eat a Mid-Afternoon Snack

YES

NO

I Eat Dinner

YES

NO

I Eat Dessert

YES

NO

I Eat Less Than 2 Hours Before Bedtime

0-2 Times Per Week

More than 3 Times Per Week

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