Your Health and Wellness Evaluation
Please take a few minutes to complete your Health and Wellness Evaluation. This survey is meant as a guide to be part of a complete assessment process.
These first few questions are required and will help to give you a better evaluation of your personal health.
1.
Gender:
Male
Female
2.
Age Group:
3.
Do you drink alcoholic beverages?
Yes
No
If yes to above, how often do you drink?
1-2 drinks per week
3-4 drinks per week
5-6 drinks per week
7-8 drinks per week
9-10 drinks per week
More than 10 drinks per week
Physical Activity/Exercise
4.
On average, how many days per week do you get at least 20-30 minutes of moderate exercise?
None
4 days
1 day
5 days
2 days
6 days
3 days
7 days
Health Issues/Conditions
5.
Do you suffer from any of the following? (Please mark all that apply)
Migraine Headaches
High Blood Pressure
Arthritis
Depression
Diabetes
Heartburn/Acid Reflux
Glaucoma
Other
6.
How would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
Very Poor