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ARUP Wellness Questionnaire
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* Indicates required question
Name (First & Last)
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Your answer
Preferred Email Address:
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Your answer
Phone Number:
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Your answer
Date of Birth (mm/dd/yyyy)
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Your answer
How do you prefer us to contact you?
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Email
Phone
MyChart
In general, what are your goals?
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Corrective Exercise Program
Lose weight/fat
Gain Weight
Maintain Weight
Add muscle
Improve physical fitness
Look better
Feel better
Have more energy
Get control of eating habits
Get stronger
Improve athletic performance
Option 13
Required
Please explain the area(s) of your health and wellness that are of concern and the specific changes/improvement you want to make:
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Your answer
Have you attempted to make changes/improvements in regards to this area(s) of your health and wellness in the past, if so, what did you try?
Your answer
What has generally blocked you from making these changes in the past?
Your answer
Right now, how would you rank your overall eating/nutrition habits?
Horrible
1
2
3
4
5
6
7
8
9
10
Awesome
Clear selection
Who does most of the grocery shopping in your household?
Me
Spouse/Partner
Roommate
Children
Other:
Clear selection
Who does most of the cooking in your household?
Me
Spouse/Partner
Roommate
Children
Other:
Clear selection
Approximately how many hours a week do you engage in planned exercise?
Fewer than 2 hours
2-3
4-5
5-7
More than 7
Clear selection
What days/ hours do you normally work? (7x7's graves, etc)
Your answer
How do you feel about your schedule, time use, and overall busy-ness?
Panicked and insane
1
2
3
4
5
6
7
8
9
10
Calm and relaxed
Clear selection
Given all the demands of your life, what is your typical stress level on an average day?
No stress
1
2
3
4
5
6
7
8
9
10
Extreme stress
Clear selection
On average, how many hours per night do you sleep?
4 or fewer
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
Clear selection
How would you rank your overall health right now?
Worst
1
2
3
4
5
6
7
8
9
10
Awesome
Clear selection
What do you expect or hope for from me as a coach?
Your answer
What days/times work best to meet with a wellness coach. Our hours are M-Th 7:30-6pm, Friday 7:30-4pm. Once you submit this form, a member of the Wellness Team will contact you to set up an appointment.
*
Your answer
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