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Evaluation Questionnaire
For a more accurate evaluation, please be as detailed as possible when answering questions.
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Indicates required field
Name
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First
Last
Email
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
What is your profession?
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How did you hear about WellPower?
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Do you currently do any exercise or sports?
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No
Yes
If yes, please list below kind of exercise/sport and amount per week:
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What types of exercise or sports have you done in the past?
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Are there any personal barriers to you exercising?
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No
Yes
If yes, please list barriers below:
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Any specific fitness related goals or personal goals?
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No
Yes
If yes, please list goals below:
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How is your sleep?
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8+ hours and very restful
<8 hours wake up tired
<8 hours hard to fall asleep
<8 hours hard to stay asleep
Other
If Other please specify:
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How many hours a day do you DRIVE?
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<1 hour
1-2 hours
3-4 hours
5+ hours
How many hours a day do you STAND?
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<1 hour
1-3 hours
4-7 hours
8+ hours
How many hours a day do you SIT?
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<1 hour
1-3 hours
4-7 hours
8+ hours
Are you currently taking any medications?
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No
Yes
Please list all medications currently taking:
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Are you currently taking any dietary supplements?
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No
Yes
Please list all dietary supplements currently taking:
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What other therapies are you CURRENTLY doing? Number of times per month?
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When answering these next set of questions, please try and think back to anything that has EVER happen to your physical body. IE: car accidents, sprained ankles, childhood surgeries or injuries, cosmetic procedures, etc.
Please list all prior surgeries including date and type of surgery:
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Please list all prior injuries including date, kind of injury, and how you injured it:
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Please list anything else you feel is relevant for us to know:
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Do you agree to sharing this information for evaluation with WellPower, LLC and release WellPower, LLC from liability in the case of injury in this program?
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Yes
Submit
Assessment Payment Options
Assessment $52.50 USD
1x per week assessment (1 month) $131.25 USD
2x per month assessment (1 month) $78.75 USD
30 minute video conference $42.00 USD
60 minute video conference $84.00 USD
Details of Program Pricing