Holistic Health Questionnaire

Congratulations on the commitment you’ve made to yourself! You are AWESOME.

This form may take a little while, but you are worth it!

[The information submitted in this form is 100% confidential. Please only share what you are comfortable with.]

CONTACT DETAILS

Name

YOUR INTENTION

Why were you interested in signing up for a personalised wellness plan? What are your main concerns? What specifically are you hoping to receive support with?

PERSONAL VISION

What does 'optimal health' look like to you?

What are your wellness goals/aspirations?

Are there any specific results you'd like to achieve on your wellness journey?

HEALTH HISTORY

Gender

Age

Current Weight (if applicable)

Weight 3 Years Ago (if applicable)

Do you have any health concerns?

Has your health changed over the last 5 years? If so, how?

Are there any medications you take that you think I should be aware of?

Do you take any supplements? If so, which ones?

Is there anything else about your health (past or present) that you think would be important to mention?

LIFESTYLE INFORMATION

How would you describe your lifestyle?

What does an average day in your life look like?

What is your living situation like?

What motivates you? Do you struggle with motivation? If so, what do you tend to do in those moments?

What is your occupation? And, how does your job affect your lifestyle? (Eating habits, sleeping habits, mental health/stress levels etc.)

Tell me about your sleep. How many hours of sleep do you usually get? Do you find it hard to fall asleep? Do you wake up frequently throughout the night or sleep soundly? What times do you usually go to sleep around?

I'd love to know about your evening routine. What does the last few hours before bedtime look like from your eyes?

I'd love to know about your morning routine. What does the start of your day look like? What are a few things you do in the first hour that you're awake?

Do you have any self care habits or routines? How often do you practice these habits? What has your journey of self-love been like in the past? How would you describe your self-love journey at the moment?

How many hours of screen-time do you average in a day? What times of the day do you spend the most time on social media/technology? What kind of things do you find yourself viewing the most?

What is your relationship with fitness? Do you have any past experience with physical activity, sports or working out?

Do you have any physical challenges or limitations?

How much exercise do you get in a day? Day to day, what kind of movements/workouts do you typically do?

What types of exercise do you enjoy the most?

Is there any particular types of fitness/workouts you're curious to try or know more about?

Do you smoke cigarettes? Or, do you take any other substances? If so, could you tell me more? (no judgement ❤️)

Is there any else about your lifestyle that you'd like to mention?

NUTRITION INFORMATION

What is your dietary preference? (Standard diet, vegan, vegetarian, gluten free or other?)

Do you have any allergies or food sensitivities?

What are some breakfast options that you'd have on a typical day?

What are some lunch options that you'd have on a typical day?

What are some dinner options that you'd have on a typical day?

What are some snack options that you'd have on a typical day? What times do you find yourself snacking most frequently? Do you have any specific cravings?

How comfortable are you with cooking? Do you enjoy getting creative in the kitchen, or do you prefer simple n' easy meals?

How many cups of water do you consume in an average day?

Do you consume alcohol? If so, how much would you say you consume? (no judgement ❤️)

What other kinds of drinks do you consume on an average day? How many cups (guesstimate)?

Are there any specific dietary changes that you're hoping to make?

What kind of questions do you have in regards to food and nutrition?

What are a few examples of your favourite foods/meals? What are you go-to's?

If you had to eat one thing for the rest of your life, what would it be?

Is there anything else about your diet that you'd like to mention?

HOLISTIC INFORMATION

How would you describe your mindset at the moment?

Are there any challenges you foresee that you might run into with your mindset/headspace?

Are there any struggles or upcoming challenges you foresee that you might face in your fitness/exercise journey?

Are there any struggles or upcoming challenges you foresee that you might face with changing up your diet or lifestyle?

Are there any other possible challenges ahead that you feel might arise?

What is motivating you to create change in your life? How will you, and those you love, benefit from your personal transformation?

Is there anything else you'd like to mention to Cass before she begins putting together your personalised wellness package?