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health

ASSESSMENT

I’m a firm believer that each person is whole when all parts are functioning at their highest level. Many people want to focus on just exercise or nutrition, thinking that will fix their body and make them right. Others think if they just develop their mind and mental acuity, they will be at their best, and still others focus only on spirituality and connection with self and community. All of these parts are important and when one falls out of balance, the others suffer too. I am not a counselor or a therapist, but I will encourage you to explore all areas of growth in order to feel your best and be your best! If some of these questions seem strange, just trust me. They matter.

First Name

Last Name

SLEEP

How many hours do you usually sleep at night?

What time do you usually go to bed?

Do you have a bedtime routine? (reading, watching TV, being on your phone, hot tea, a shower/bath)

Do you sleep with any lights on or background noise?

Do you sleep alone?

Yes

Approximately what temperature do you keep your room at night?

How do you sleep? (heavy, light, fall asleep quickly, difficulty sleeping, mind races)

What time do you usually wake up?

How do you feel when you wake up? (rested, groggy, cheerful, anxious, hungry)

Do you wake up to an alarm or on your own?

Are your weekend sleep patterns similar or different from weekdays?

If different, how so?

Do you nap during the day?

Yes

Do you generally feel good about sleep or do you think you could use some work here?

NUTRITION

Do you enjoy food, or does it feel like a bother or an obsession?

Do you eat at regular meal times, or more when you feel hungry?

Do you enjoy preparing food or find it a bother?

Do you eat a variety or foods or mostly the same things every day?

Have you ever counted calories, macros or been overly concerned with how many calories you consume?

Do you ever eat when you are bored?

Yes

Do you ever skip eating or forget to eat because you are too busy?

Yes

Do you mostly eat alone or with friends and family?

How soon after waking do you usually eat?

Do you snack before bedtime or in the late evening? If so, what do you usually eat?

Do you often overeat?

Do you ever feel digestive discomfort after eating?

Do you ever “stress eat” or do you avoid food when stressed?

Do you have any food allergies, sensitivities or preferences?

What foods do you most dislike?

What are your favorite foods?

What beverages do you usually drink?

Do you drink water daily? How much?

How often do you eliminate solid waste?

What color is your urine?

Do you generally feel good about your nutrition or do you think you could use some work here?

SUBSTANCES/SUPPLEMENTS/MEDICINE

Do you use any supplements? (probiotics, vitamins, protein powder, workout stimulants)

Do you take any prescription medication? If so, what and for how long?

Do you use any over the counter medications? If so, what and how often?

Do you drink coffee or caffeinated beverages? If so, how many a day?

Do you drink alcohol? If so, what types, and how often?

Do you use any tobacco products?

Are there any other substances you have used in the past or are using now that may impact your health?

EXERCISE/MOVEMENT

Would you consider yourself an active person?

Do you exercise? If so, how often? Do you enjoy it?

What are your favorite ways to move your body? (run, yoga, weights, sports)

What sports do you enjoy, if any?

Do you exercise for fun, for health or both?

Do you ever use exercise to punish yourself?

Do you ever use exercise to counteract eating too much?

Do you use any substances to enhance your athletic performance?

Do you usually exercise alone or with friends/family?

Do you prefer exercising indoors or outdoors?

Thanks for submitting!

SARAH PAY

WELLNESS