WELLNESS QUESTIONNAIRE

This confidential questionnaire is the first step in learning about programs that will help get on track fast.

Name:
Phone:
Email:

Please check any of the following that apply:

I eat 3 servings of lean protein daily?
I eat 5-7 servings of fruits and vegetables daily?
I eat 1-2 servings whole grains daily (bread, pasta, brown rice)?
I eat 3 servings per week ocean caught fish?
I eat fried foods more than once per week?
I experience frequent digestion discomfort?
I have a regular, daily bowel movement?
I exercise for 30 minutes a minimum of 3 times per week?
I drink 8 glasses of water per day?
I eat out 3 or more times per week?
How much weight would you like to lose?