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Survey
First name
Last name
Email
How would you describe your current physical/mental health status?
*
Excellent - I wake up with good energy that lasts me all day
Good - Some days I have good energy, and I’d love more of those. I do my best to take good care of myself.
Fair - My health has taken a back seat to everyone else’s needs, but I’m still happy to be able to do as much as I do.
Poor - I’m experiencing health setbacks at the moment (and all the doctor can tell me is “stress less”)
I prefer not to disclose
How would you describe the gap between your current physical/mental health status and your ideal state?
*
I feel far far away from the body/energy I desire….sometimes I wonder if I’ll ever feel good again
I know there’s a lot I can be doing to improve my health, I just don’t know where to start
I just don’t have time to do the things I know I need to be doing, but I’m trying
I prefer not to disclose
What strategies or approaches are you currently employing to support your physical/mental well-being? Check all that apply.
Regular Exercise
Dietary Changes
Stress Management
Professional Counseling
Medication Management
Adequate Sleep
Mindfulness Practices
Social Connections
Hobbies and Leisure Activities
Other
Have you worked with a Personal Wellness Coach before?
*
No
Yes
If you were to hire a Personal Wellness Coach, what would you look for? Check all that apply.
Experience and Credentials
Tailored Approach
Effective Communication Skills
Proven Track Record
Holistic Approach
Accessible and Supportive
Goal-Setting Expertise
Motivational Skills
Flexibility and Adaptability
Gender-Sensitive Approach
Other
Would you be interested in a consultation to discuss how Personal Wellness Coaching can benefit you?
*
Yes, definitely
Maybe
Not sure
Unlikely
No, not interested
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