PhoenixWay Wellness Survey Update

Personal Information

* Indicates required field

Name *

Email *

Phone Number *

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? *

Are you cooking/eating more at home? *

What foods do you crave? *

Breakfast *

Lunch *

Dinner *

Liquids *

Snacks *

Late Night Snacking? *

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.

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