Wellbeing Survey
Double D Ranch - Health & Wellness
Thank you for taking the time to complete and submit this survey.
Interview Date
Email
*
First Name
*
Last Name
*
Address
*
City
*
State
*
Postal code
*
Phone
*
Preferred Method(s) of Contact
Preferred Method(s) of Contact
phone
text
email
FB messenger
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Date of birth
Age
Their Timezone
How did you hear about our program?
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AWAKEN...
AWAKEN...Discover where you are and where you want to be!
Describe where you would like to be in your Health...
Please describe WHY you are interested in getting healthy.
When was the last time you remember feeling your best in your health or being at your ideal weight or size?
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Medical
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Are there any food or other allergies that I should be aware of?
If Nursing, How old is your baby?
Are you taking any medications for:
Diabetes
High blood pressure
High Cholesterol
Thyroid**
Lithium*
Coumadin (Warfarin)***
Do you have the following...
Diabetes - Type 1
Diabetes - Type 2
High blood pressure
Gout
Are you taking other medications or have other medical conditions that could influence which program we choose? *
*Lithium: The healthcare provider may wish to adjust frequency of lab work for the client and monitor
**Thyroid Medications: The healthcare provider may wish to monitor thyroid hormone levels while the Client is on the Program and adjust medication.
***Coumadin (Warfarin): The healthcare provider may wish to review food choices, conduct lab work and/or adjust medication.
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Sleep
How many hours of sleep do you usually get?
What time do you typically go to bed?
How is your quality of sleep?
What time do you typically wake up?
Do you wake up feeling rested?
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Hydration
How much of the following do you drink?
Coffee
Water
Soda
Tea
Alcohol
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Motion
How would you rate your Energy level?
How many times a week do you exercise?
What physical activities do you participate in?
Are there things you can't do that you would like to be able to do?
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Stress
How would you rate your stress level?
What do you do for work?
How much do you enjoy what you do?
Are there other stressors in your life?
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Eating Habits
How many meals per day do you eat?
When do you eat your first meal?
Do you snack between meals?
Yes
No
When do you eat your last meal?
What kind of snacks?
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Weight
Current Weight
Goal Weight
Height
Have you tried to lose weight before?
Yes
No
What has been most difficult about losing/maintaining weight in the past?
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Surroundings
How healthy would you rate your surroundings?
DO you have healthy & active friends, supportive family, keep junk food in the house, etc?
Is there anyone in your life who would like to get healthy with you?
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