Wellness Analysis

If you are a Company, Personal Trainer, Wellness Coach, etc., we can add your name to the top of the wellness analysis report for a more personalized look.

If you would like a personalized questionnaire to hand out, just Email Us.

The Wellness Analysis is a questionnaire that analyzes lifestyle behaviors in the areas of exercise, nutrition, safety, tobacco, and stress. You will be provided, by Email, a 9-page profile report that details specific recommendations to help guide you to optimum health. Your personalized feedback report will help you understand your current health status and inspire the choosing of healthier lifestyle choices.

Your personal wellness analysis will be compiled from the information you provided so be honest with your answers.

1.) Fill out and submit your responses along with your payment information (located at bottom of form).

2.) Be honest and answer all questions.

Your 9-page report will be Emailed back to you in (Adobe, PDF format) within 24-hours.

The information you provide will be kept confidential.

Price $49

Donations

If you would like to make a donation for a friend of loved one for a Wellness Analysis, simply click the Donation Button. Please Email Us and let us know who you are donating to.

Please fill out the following information so we may process your answers. When your payment has been approved your report will be Emailed to you.

If you rather the questionnaire can be Emailed to you and all you have to do is fill it out and fax it to us. We will Email you your results.

First Name Last Name

Date of Birth M / D / Y Gender

State Zip Code

Home Telephone Cell Telephone

Work Telephone Email

Company (if applicable)

Remember, be honest with all your questions.

Do you believe your current lifestyle:

Of all the possible actions you could take in order to prevent disease and maintain/enhance your health, how much do you estimate you are currently doing?

Which area of behavior would you most like to change in order to improve your health?

Q4 Have you ever lost ten percent of your weight through dieting/exercise and then, gained it back?

Q5 Have you recently had a significant loss of weight, and you’re not sure why?

Q6 How do you feel about your current weight?

Q7 Do you accumulate at least 30 min. of physical activity on most (5-6) days of the week? The activity must be moderate to high intensity like walking, house work, cycling, stair climbing, swimming, running, or sport games.

On average, how many times a week do you perform aerobic exercise for at least 20 continuous minutes? Examples are fast walking, hard cycling, running, swimming, and vigorous sports.

If you answered “Never” to this question, go to question 12

Q9 When you do aerobic exercise, how much time do you spend in the activity?

Q10 How would you describe your aerobic exercise?

Q11 Do you warm up before and cool down after aerobic exercise?

Q12 Do you participate in strength training activities (weight lifting)?

Q13

How often do you stretch your muscles in order to gain flexibility?

Q14 How often do you perform abdominal exercises, such as sit-ups, which are intended to strengthen the abdomen?

Q15 What is the biggest barrier to increasing and/or maintaining your level of exercise?

Q16 How often do you eat breakfast?

Q17 On average, how many servings of foods which are high in calcium do you eat each day? Foods such as milk, cheese, yogurt, and green, leafy vegetables are high in calcium.

Q18

On average, how many servings of foods which are high in fiber do you eat each day? Foods such as beans, whole grains, cereals, fruits, and vegetables are high in fiber.

Q19

On average, how many servings of foods which are high in fat do you eat each day? Foods such as whole milk, cheese, eggs, red meat, fried foods, and some desserts are high in fat.

Q20 How often do you choose low fat or low cholesterol foods?

Q21 How often do you add salt to your cooking or add it to your food at the table?

Q22 How often do you read nutrition labels on food packages?

Q23 On average, how many alcoholic beverages do you have in a week? A drink is a 12oz. bottle or can of beer, a 5oz. glass of wine, a 12oz. wine cooler, or a shot of liquor.

If you answered “Less than 1 drink/week” to this question, go to question 26.

Q24 On average, how many drinks do you have in one sitting?

Q25

On average, how many days per week do you drink alcohol?

Q26 How many times in the last month did you ride in a car when the driver was under the influence of drugs or alcohol?

Q27 What percent of time do you buckle your safety belt when riding in a car?

Q28 How would you describe your driving behavior?

Q29 How often do you wear sunscreen or protective clothing when you are in the sun?

Q30 When riding a bicycle, motorcycle, or similar vehicle, how often do you wear a helmet?

Q31 Does your home have a smoke detector that works?

Q32 When lifting objects, even when they are not very heavy, do you lift them properly? Lifting them properly would be when you bend at your knees and use your leg muscles to do most of the lifting, while keeping your back straight.

Q33

What is your exposure to second-hand smoke?

Q34 Do you use cigars, pipes, or smokeless tobacco such as chewing tobacco, snuff, or pouches?

Q35 Do you smoke cigarettes?

If you answered “Used to smoke” or “Never smoked” to this question, go to question 37.

Q36 What is the primary reason you have not quit smoking?

Q37 During the past year, how much effect has stress had on your health?

Q38 Do you think your current level of stress is high enough to affect your health or quality of life?

Q39 How effective do you think you are in dealing with the stress in your life?

Q40 Do your sleep patterns promote good health?

Q41 How often do you feel tense, anxious, or upset?

Q42 In general, do you have emotional support from others to help you deal with stress?

Q43 How often do friends or relatives suggest that you should slow down, take life easier, or relax more?

Q44 How often do you find yourself getting irritated or annoyed with others?

Q45 How often do you feel a chronic sense of struggle with daily events?

Q46 Have you suffered a personal loss or misfortune in the past year that had a serious impact on your life?