Free Evaluation | Organic'ly Wellness

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What are Your Top 3 - 5 Health Concerns?
Health Concern 1*
Health Concern 2*
Health Concern 3*
Health Concern 4
Health Concern 5
What would you like to gain from a health and nutrition program? What are your personal goals?
How would you best describe your daily activities?*
- Sedentary – spend most of the day sitting (i.e. desk job)
- Moderately active – spend at least half of the day on your feet (i.e. teacher)
- Active – spend at least half of the day doing physical activity (i.e. flight attendant)
- Very Active – spend at least half the day doing heavy physical activity (i.e. construction)
On average, how many hours per day are you sitting (at work, TV, etc)?*
Please enter a number from 0 to 24.
What types of hobbies and activities do you enjoy?*
How many days per week do you exercise?*
Please enter a number from 0 to 7.
What type(s) of exercise do you engage in?*
Examples: resistance training, strength training, cardiovascular, high-intensity interval, yoga, etc
For how long do you typically exercise?
On a scale of 0-10 how intense is your exercise?*
0 being barely increasing your heart rate, 10 being giving it everything you have

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On average, how many hours do you sleep each night?*
Please enter a number from 0 to 24.
What time do you usually go to bed?*

: Hours

Minutes

AM/PM
Do you sleep well?*
Do you wake up during the night?*
What time do you wake up during the night?*

: Hours

Minutes

AM/PM
Do you know why you wake up during the night?*

Examples: to urinate, your mind is racing, etc.?
What time do you usually wake up in the morning?*

: Hours

Minutes

AM/PM
How do you typically feel when you wake up in the morning?*

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How much PURE water do you drink per day in ounces?*
Please enter a number from 0 to 400.
Don’t include beverages containing water like juice or tea
How often do you drink alcohol?*

Examples: never, daily, twice per week, etc.
How many alcoholic drinks per month?*
Please enter a number from 0 to 500.
What else do you drink on a regular basis?
- Coffee
- Tea
- Soda
- Juice
- Energy Drinks
- Other
If "other" please describe.
What % of your food is cooked/prepared at home?*
Please enter a number from 0 to 100.
What does a typical breakfast look like for you?*
What kinds of fats do you cook with?*
Examples: Butter, olive oil, canola oil, “I don’t know”, etc.
In your opinion, what are the three least healthy foods you eat each week and why?*
What is your favorite food?*
What is your least favorite food?*
What do you crave?*
Examples: Sugar, salt, bread, coffee, etc.
List any protein powders or protein bars you eat, if any.
List any known food allergies and/or sensitivities.

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Are you currently taking any vitamins, minerals, herbs, homeopathic remedies, prescription or non-prescription medications, aspirin, laxatives, diet pills, or any other supplements?*
Please list below including dosages/amounts.*
Do you have any know allergies/reactions to any medications, supplements, or herbs?*
Please list allergies/reactions.*

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Are you currently under a doctor’s/practitioner’s care for a specific issue?*
What is your doctor’s/practitioner’s name and what treatments are you undergoing?*
Have you ever been diagnosed with a medical condition?*
Please explain the diagnosis.*
Have you ever been seriously injured, hospitalized, or suffered from a disease?*
Please explain.*

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Do you smoke?*
How many cigarettes per day?*
Please enter a number from 0 to 50.
Are you regularly exposed to secondhand smoke?*
How many days per week are you exposed to secondhand smoke?*
Please enter a number from 0 to 7.
Have you been exposed to toxic substances at work or home?*
Explain your exposure to toxic substances.*
Name
This field is for validation purposes and should be left unchanged.

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What are Your Top 3 - 5 Health Concerns?