Wellness Questionnaire

How often do you feel stressed?

All of the time

Most of the time

Some of that time

Rarely

Never

What do you consider the main source of your stress?

Work

Family/Friends

Medical

Financial

Relationship Issues or Status

N/A

Other:

Have you ever sought help to manage your stress?

Yes

No

Yes (please specify if you would like)

If so, did it help?

Yes

Somewhat

No
Do you feel that you have aged due to any recent or chronic stress?

Yes

No

What activities do you do for fun or relaxation and how many times/week?

Meditation

Deep breathing

Art/music

Cooking

Writing

Reading

Travel

Volunteer work

Other:

Do you exercise and how many times per week

1-3

4 or more

Please specify type of exercise

Yoga

Dance

Biking

Running

Weight training

Walking
 Sports

Other:

In the past month, how often have you

Very Good

Good

Fair

Poor

Very Poor

Had trouble sleeping?

Woke up earlier than desired?

Woke up for no reason during the night?

Felt tired during the day?

Do you feel you have aged due to your lack of sleep?

Yes

No

How many cups of coffee or caffeinated beverages do you normally consume daily?

1-3

4-6

7 or more

How many 8 oz. glasses of water do you normally drink daily?

0-2

3-6

6-8

9 or more

Are you getting 3-5 servings of fruits and vegetables/day?

Yes

No

Do you usually

Eat out
 Cook at home

Both

Would you say your diet is balanced?

Yes

No

Do you eat organic foods?

Yes, always

Most of the time

Some of the time

Very rarely

Never

Do you smoke?

Yes

No

If so, how many years?

How many packs of cigarettes/day?

Do you drink?

Yes

No

If so, how many drinks/week?

Do you use sunscreen?

 Yes

No

What supplements do you use, if any?

What would you say is the primary factor in your aging?

What is a positive action you are now taking to help prevent an accelerated Aging process?

What are you anti-aging and beauty, and heath and wellness goals?

Would you like to schedule a consultation to address any of the above concerns?

Yes

No

Name

Email

Phone