Wellness Questionnaire

1Personal Info

2Gut Health

3ENERGY

4Mental Health

5Immune System

6Toxins

7Skin Health

8Inflammation

9General

Contact(Required)

First Name Last Name

Address(Required)

ZIP Code

Date of Birth

MM slash DD slash YYYY

Email Address(Required)

Phone(Required)

Preferred Time for us to contact you via phone

Where did you hear about us?

Gut Health

Do you suffer from any constipation, bloating or indigestion?

A. Yes

B. No

On average, how many bowel movements do you have per day?

Only 1-3 times per week

Less than 1

2-3+

Do you take daily prebiotics and probiotics?

A. No

B. Yes

Do you suffer from any yeast infections?

A. Yes

B. No

Do you eat boxed or processed foods weekly?

A. Yes

B. No

Are you currently trying to lose weight?

A. Yes

B. No

ENERGY

How is your energy level throughout the day?

A. Low

B. Average

C. Above Average

Do you drink coffee every day?

A. 3+ cups

B. 0-2 cups

Mental Health

Do you experience issues with anxiety and/or depression?

A. Yes

B. No

Are you experiencing any issues with your memory and/or ability to focus?

A. Yes

B. No

Do you have ongoing stress in your life (emotional, jobs, family)?

A. High Stress Level

B. Moderate Stress Level

C. Low Stress Level

Immune System

Do you often get a cold or the flu?

A. Yes

B. No

How much fruit and vegetables do you eat daily?

A. Very Little

B. 1-3 servings

C. 3+ servings

Toxins

Do you buy organic fruit and vegetables?

A. No

B. Yes

On average how many ounces of water do you drink per day?

A. 0 - 30 Ounces

B. 30 - 60 Ounces

C. 60 Ounces +

How often do you exercise per week?

A. 0 time

B. 1-2 times

C. 3+ times

How many alcoholic drinks and/or sodas do you have per week?

A. 5+

B. 1-5

C. 0

Skin Health

Do you have any skin issues such as eczema, psoriasis, acne, fungus, rashes or dry skin?

A. Yes

B. No

Would you like your skin to appear more radiant?

A. Yes

B. No

How important is the appearance of your skin?

A. Extremely Important

B. Not Very Important

Inflammation

Do you have any nagging injuries or chronic pain? Even if mild (Ex. Back pain, sciatic pain, knee pain etc)

A. Yes, severely

B. Yes, moderately

C. No

Have you had any surgeries in the past 3 years? Including dental or cosmetic

A. Yes

B. No

Do you often experience headaches or migraines?

A. Yes

B. No

General

Have you had organic raw cold pressed juice before?

A. Yes

B. No

Have you ever juiced regularly before?

A. Yes

B. No

Are you familiar with the difference between using a cold pressed juicer and a traditional centrifugal juicer or blender?

A. Yes

B. No

Do you take supplements, prescriptions, vitamins, etc

Do you have any health issues or challenges that were not already covered by the previous questions? Please explain in detail. (Example:, Weight, arthritis, High Blood Pressure, inflammation, diabetes, cholesterol etc)

Do you have any food allergies?

Answering these questions is going to help us customize both juicing and healthy lifestyle recommendations. Our goal is to understand a picture of your overall food and health habits to help you reach your goal of optimal health and vitality.

We look forward to receiving your answers to the above questions and to help guide you in your journey towards a healthy life.

Disclaimer: This questionnaire is confidential and used for wellness coaching purposes only.