Health and Wellness Questionnaire | TLC Health and Wellness

Name *

Date of Birth *

Gender at Birth *

Male
Female

Gender you Identify as

Male
Female
Non binary
Other

Contact Number *

Email address *

Address *

Are you currently under the care of a healthcare provider? If yes, please specify reason and provider:

Do you have any known medical conditions? If yes, please list:

Are you currently taking any medications or supplements? If yes, please list:

Do you have any allergies? If yes, please specify:

Have you had any surgeries or hospitalisation in the past? if yes, please provide details:

Do you smoke?

Yes
No
I vape

Do you consume alcohol?

No
Yes- 1 or 2 a week
Yes- 3 or 4 a week
Yes- alcohol may be a problem for me

How would you describe your diet? (e.g. balanced, vegetarian, low-carb)

Do you engage in regular physical activity? If yes, please specify frequency and type of activity:

How would you rate your stress levels on a scale of 1 to 10? (1 being low, 10 being high)

What are your primary health and wellness goals?

Are there any specific challenges or obstacles you anticipate in achieving these goals?

How motivated are you to make changes to improve your health and wellness? (scale of 1 to 10)

What are your primary work goals?

Are there any specific challenges or obstacles you anticipate in achieving these goals?

Any family history of significant medical conditions? If yes, please specify:

Are there any specific concerns or areas you would like to address during the assessment?

Please tell me anything else you think is relevant: *

DISCLAIMER: *

By submitting this form, you acknowledge that the information provided is accurate to the best of your knowledge and understand that this assessment does not replace professional medical advice. It will be used solely for the purpose of guiding your health and wellness plan. Pick tick to confirm that you understand and agree.