Health & Wellness Survey

Patient Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email address *

Wellness Questions

On a scale of 1 to 5, how is your physical wellbeing? *

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Prefer not to answer

On a scale of 1 to 5, how is your mental/emotional wellbeing? *

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Prefer not to answer

Physical Questions

On a scale of 1 to 5, how satisfied are you with your ability to move your body to accomplish daily activities? *

Our wellbeing is impacted by the amount and kind of movement we make. Moving the body can take many forms, such as exercising, walking, gardening, lifting groceries, climbing stairs, etc.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Prefer not to answer

On a scale of 1 to 5, how satisfied are you with your current diet? *

What we eat and drink can have a huge effect on how we experience life, both physically and mentally. Energy, mood, weight, how long we live, and overall health are all impacted by what and how we choose to eat and drink.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Prefer not to answer

On a scale of 1 to 5, how satisfied are you with your ability to sleep and recharge? *

Our bodies and minds must rest and recharge in order to optimize our health. Getting a good night's rest, as well as recharging our mental and physical energy throughout the day are extremely important.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Prefer not to answer

Mental / Emotional Questions

On a scale of 1 to 5, how satisfied are you with your financial situation? *

Our financial wellbeing, including the ability to afford daily expenses, save for retirement, and avoid unnecessary stress with a spouse or partner, can have outsized impacts on our wellbeing.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Prefer not to answer

On a scale of 1 to 5, how satisfied are you with the personal relationships, connections, and development opportunities in life? *

Our relationship with family, friends, co-workers, and community have a large impact on our health and wellbeing. Connecting with someone may provide a sense of meaning and purpose, peace, or comfort. Aligning our work and personal activities with what really matters to us or what brings us joy can have a big effect on our health and outlook on life.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Prefer not to answer

On a scale of 1 to 5, how satisfied are you with the professional relationships, connections, and development opportunities in your life? *

Professional relationships and opportunities to grow can influence our wellbeing and sense of purpose. Feeling supported by colleagues, having access to mentorship and development, and doing work that feels meaningful can all contribute to fulfillment and quality of life.

1 - Poor

2 - Fair

3 - Good

4 - Very Good

5 - Excellent

Prefer not to answer

Care Priorities

Is there anything else you would like to share with us so that we can best support your physical and mental health?

Treatment, Consent & Notice of Privacy Practices