Wellness Questionnaire

On a scale of 1-10 with 10 being excellent and 1 being poor, please answer these assessment questions about yourself.


Please answer yes or no to the following questions:

17. Are you currently being treated for any physical or emotional condition? If so, for what condition(s) are you being treated?

18. Do you currently smoke?

19. Do you have a clear vision of your ideal health?

20. Do you have key relationships that would support you in changing your health?

21. Do you have a computer and enjoy using the Internet?


Please comment below in response to these questions:


Thank you, we look forward to evaluating your responses and sending you the results of your evaluation and coaching options that would support you in your health goals.

Sex