Foundations Form – ALX Wellness

Personal Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number

Gender

Occupation

Emergency Contact Name, Relationship, and Phone # *

What are your health and wellness goals? Why are they important to you? *

Have you experienced any barriers or challenges to accessing healthcare?

How many hours do you sleep per night, on average? *

How would you describe your quality of sleep?

How many hours per week do you typically work? *

Do you experience any of the following?

Reproductive HealthInfertilityIrregular menstrual cycleLow libidoOther

Hormonal HealthThyroid conditionToxin exposureSigns or symptoms of hormonal imbalanceOther

Brain HealthBrain fogDifficulty concentratingForgetfulnessOther

Other

Describe your current relationship with food and what a day of eating looks like. *

Do any of the following apply to you?Challenges with preparing mealsChallenges with access to foodDifficulties chewing or swallowingPoor appetite

Do you use any of the following?AlcoholTobacco productsMarijuanaOther substances

How would you describe your overall mental and emotional health? *

Rate how often you experience each of the following from 1 (never) to 5 (often):

What role does spirituality play in your life, if any?

What are the important relationships in your life?

What hobbies or recreational activities do you enjoy?

What role does movement (including sports, exercise, and other forms of physical activity) play in your life? *

Is there anything else you'd like to share?

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