PhoenixWay Wellness Survey Update

Personal Information

* Indicates required field

Name *

Email *

Phone Number *

Health Information

What positive changes have you noticed since you started counseling/coaching? *

How is your sleep? *

Medications or supplements? *

How is your mood? Please describe. *

How is your anxiety? Please describe. *

Constipation or diarrhea? *

Pain, stiffness, or swelling? *

Any changes with weight? *

What are your main physical and/or mental health concerns at this time? *

Food Information

Are you cooking/eating more at home? *

What foods do you crave? *

What is your diet like these days?

Breakfast *

Lunch *

Dinner *

Liquids *

Snacks *

Late Night Snacking? *

Other Information

What kind of exercise are you doing? *

How frequently? *

How is your work going? *

How are things going in your spiritual practice? *

How are things going in your primary relationship? *

How are your relationships with family, friends, coworkers, clients? *

Anything else you'd like to add? *

Please note that all information submitted here is private, confidential, and protected by law. Please also note that the form will not successfully submit unless ALL required fields (marked with an asterisk) are completed.

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Personal Information

Health Information

Food Information

What is your diet like these days?

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