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Initial Assessment

Embark on a transformative journey to better health with Mindful Nutrition & Wellness Solutions. Start your personalized wellness plan with an initial assessment that will pinpoint your current needs and goals, setting the stage for lasting change.

Client Intake

This assessment is designed to help you evaluate different areas of your health and wellness, including physical health, nutrition, lifestyle habits, emotional well-being, and social connections. Answer each question honestly to determine where you currently stand and identify areas for improvement.

Birthday
Month
Day
Year
What are your top 3 wellness goals?
Are you currently dealing with a chronic health challenge that has lasted more than three months?
Yes
No
How often do you experience bowel movements?
Twice a day on a daily basis
At least once a day
Irregularly
How frequently do you engage in physical activity that makes you sweat or increases your heart rate?
Less than once a week
1–2 times a week
3 times a week
4 or more times a week
How much water do you drink daily? (Goal: ½ your healthy body weight in ounces)
Less than 16 oz
16 - 32 oz
33 - 64 oz
65+ oz
How often do you consume high-fiber foods (whole grains, legumes, fruits, vegetables, nuts, seeds)?
Rarely
A few times a week
Daily
How frequently do you consume refined or processed sugar? (White/brown sugar, soda, candy, pastries, etc.)
Rarely/Occasionally
A few times a week
Every day
Not at all
Do you suspect or have a known vitamin or mineral deficiency?
Yes
No
Unsure
How often do you rely on supplements or vitamins for nutritional support?
Daily
A few times a week
Occasionally
Never
How frequently do you try new fruits, vegetables, or whole grains?
Regularly
A few times a week/month
Rarely/Occasionally
Never
How much of your diet consists of processed or pre-packaged foods (boxed, bagged, jar, canned, frozen, or fast food)?
More than 50%
25-50%
15% or less
Do you smoke?
Yes
No
How often do you consume alcohol?
Never
1 - 3 times per week/month
3 - 4 times per week/month
More than 5 times per week/month
Do you believe your health challenges are primarily caused by genetics or lifestyle choices?
Mostly genetic (I can't do anything about it)
Mostly lifestyle (I choose how live with what I consume and do)
A combination of both
How would you describe your sleep habits?
I wake up feeling rested and refreshed
I wake up multiple times throughout the night
I often struggle to fall or stay asleep (insomnia)
I sleep but rarely feel well-rested
Have you experienced chronic stress (a situation that is ongoing/without a definitive ending) for more than three months?
Yes
No
Unsure
How often do you feel stressed or overwhelmed?
Daily
A few times a week
Occasionally
Rarely

Although you're functioning through it doesn't mean you're not feeling stressed or as if some things are becoming too much.

Do you actively participate in a faith-based or spiritual community?
Yes
No
Unsure
How would you describe the quality of your relationships?
Mostly positive and mutually beneficial
Somewhat fulfilling, but could be improved
Often stressful or draining
I feel disconnected from others
How well do you process your emotions?
I can easily identify and process my emotions
I sometimes struggle with processing emotions
I often feel overwhelmed and avoid emotional expression
Are you satisfied with your life accomplishments so far?
Yes, every day
I feel content but want to achieve more
I often feel like I’m not where I want to be
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