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Evaluation Questionnaire

For a more accurate evaluation, please be as detailed as possible when answering questions.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What is your profession? *

How did you hear about WellPower? *

Do you currently do any exercise or sports? *

No Yes

If yes, please list below kind of exercise/sport and amount per week: *

What types of exercise or sports have you done in the past? *

Are there any personal barriers to you exercising? *

No Yes

If yes, please list barriers below: *

Any specific fitness related goals or personal goals? *

No Yes

If yes, please list goals below: *

How is your sleep? *

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: *

How many hours a day do you DRIVE? *

<1 hour 1-2 hours 3-4 hours 5+ hours

How many hours a day do you STAND? *

<1 hour 1-3 hours 4-7 hours 8+ hours

How many hours a day do you SIT? *

<1 hour 1-3 hours 4-7 hours 8+ hours

Are you currently taking any medications? *

No Yes

Please list all medications currently taking: *

Are you currently taking any dietary supplements? *

No Yes

Please list all dietary supplements currently taking: *

What other therapies are you CURRENTLY doing? Number of times per month? *

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: *

Please list all prior injuries including date, kind of injury, and how you injured it: *

Please list anything else you feel is relevant for us to know: *

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? *

Yes

Submit

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