Wellness Quiz

Name *

First Name

Last Name

How is your energy level?

Check all that apply.

High

Average

Low

Drops during day

Digestion

Do you have any of the following? Select all that apply.

Acid Reflux

Heartburn

Food cravings - sweet, salty

Pain in torso

Bowel Movement

Select all that apply

Regular (daily)

Irregular

Constipation

Diarrhea

Solid

Loose

Emotions

When you lean towards an emotion, what is it?

Anxiety

Easily Irritable

Sad

Anger

Worrisome

Fearful

Menstrual Cycle

Select all that apply

Regular

Irregular

Cramps

Clots

Brownish discharge at beginning or end

Bright red

Dark red

Heavy

Light

PMS

Body Temperature

When others in the room feel comfortable, temperature-wise, do you feel...?

Warmer

Cooler

Comfortable

Cold hands

Hot flashes

Headaches

Select all that apply

None

Yes

Severe

Mild

Headaches - Location

Select all that apply

Forehead

Temple

Backhead

Top

Side

Urine

Select all that apply

Dark yellow

Bright yellow

Pale yellow

Clear

Cloudy

Infrequency

Incontinence

Sleep

Select all that apply

Fall asleep in less than 5 min in bed

Trouble Falling asleep

Wake from sleep during night