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RePower Your Mind-Starter Questionnaire

Preferred method of contact?
Health goals? (click all that apply)
Health History
Major health events:

Surgeries or hospitalizations:

Broken bones/ major illnesses/ or extended periods of inactivity:

Pregnancies:

Spinal and back health:
Do you experience pain that limits your desired level of activity?
Wellness/Mood:
Do life events leave you feeling mentally overwhelmed?
On a given day when you want to get things done, it is hard to choose what to tackle first?
Do you easily remember the details of new information like places, new people and new information without referring to notes?
Diet:
Is how you eat an area of focus for you?
Do you adhere any of the below diet routines? (check all that apply)
General Body Trend:

How much more or less do you weigh now than from age 25? If applicable. 

Do you consider yourself more or less fit now that age 20?

Flexibility
Muscle Tone
Cardiovascular Health

How many hours do you sleep per night?

Do you go to sleep at around the same time each day of the week?
Does it vary on weekends versus week nights?
Do you wake up in the middle of the night?