How motivated are you to achieve your wellness goals?
How satisfied are you with your current weight status?
If you are unsatisfied or neutral regarding your current weight, how important is it to you to take action to lose weight?
Have you made attempts to modify your diet or exercise routine for weight management in the past six months?
What factors do you feel contribute most to your current weight and lifestyle?
How do you view your overall diet
How important is achieving a specific weight or body image to your overall happiness or well-being?
What prompted your decision to modify your diet or exercise routine (or lack thereof) in the past six months?
How challenging do you find it to maintain changes in your diet or exercise routine?
Rate your overall energy level in the morning
Rate your overall energy level in the afternoon
Rate your overall energy level in the evening
What contributes most to your energy levels throughout the day?
On average, how many hours of sleep do you get per night?
Do you snore during the night while sleeping?
How frequently do you engage in physical exercise during the week?
Do you consume caffeinated beverages or energy drinks? If yes, how often?
How satisfied are you with your current sexual drive/libido?
What factors do you think most influence your current sexual drive/libido?
Have you noticed recent changes in your sexual drive/libido?
How does your sexual drive/libido affect your overall well-being or satisfaction?
Have you sought professional advice or treatment for concerns related to your sexual drive/libido?
Over the past few months I have noted:
Do any of the following situations trigger urinary incontinence?
How often do you experience episodes of urinary incontinence in a week?
Does your urinary incontinence impact your daily activities or quality of life?
Have you sought professional advice or treatment for urinary incontinence?
What fluids do you consume regularly? (Select all that apply)
Do you experience symptoms of dehydration like dry mouth or dizziness?
Do you feel that your hydration status affects your energy levels
I experience minor aches and pains daily including but not limited to arthritis, back pain, neck pain, knee pain, headaches, migraines.
Aches and pains limit my ability to function and complete simple tasks throughout the day.
My aches and pains limit me from exercising.
My aches and pains are located: (pick all that apply)
Massage, acupuncture, chiropractors, physical therapy has helped with my pain in the past?
I take over the counter pain medication to help with my aches and pains?
I have seeked intervention for my pain including but not limited to epidurals, cortisone injections, intra-articular injections, facet blocks, PRP injections, other
How satisfied are you with your overall appearance?
What bothers you most about your overall appearance (check all that apply)
I have a skin care routine
Do you currently have a primary care physician or family medicine doctor?
