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Jackie Ulmer's Integrative Health and Wellness Assessment

I look forward to getting to know more about you, and how I might support, encourage and assist you in creating new, "slight edge" hacks and habits to create and sustain a high functioning life in all areas.

There are 22 questions, including name and details. Answer as many as you are comfortable with and feel free to put N/A where it applies. Each question needs something in it to move forward, and N/A is just fine. Sum up anything that may have been missed in the last question.

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Question 1 of 22

First and Last Name

Question 2 of 22

Age? Height? Current Weight? Goal Weight?

Question 3 of 22

Relationship Status - Single, Married, Divorced? Anything specific about your relationships that you feel may be relevant to, or affecting your overall health and well being?

Question 4 of 22

Children? Ages? Relationship details? Is there anything about your children and your relationship with them that might be affecting your health and wellbeing? 

Question 5 of 22

Tell me a little about YOU - anything you want. Career? Stage of Life? Family? Just describe a little of WHO you are!

Question 6 of 22

What are your immediate health concerns? Please be as specific as possible.

Question 7 of 22

What are your health and overall "well being" goals?

Question 8 of 22

Have you regularly "dieted" or been part of the yo-yo diet culture - lose, gain, lose, gain more, creating a vicious cycle? 

Question 9 of 22

What are your thoughts around body image and self image?

Question 10 of 22

Any prior accidents, injuries, surgeries or illnesses that affect your health or concern you?

Question 11 of 22

Tell me about your sleep, and rate it on a scale of 1-10? How many hours per night? Concerns you have? Please be as specific as possible. Sleep is SO important and can be SO elusive.

Question 12 of 22

Current medications, supplements or therapies, including holistic that you take or use? Please be as specific as possible.

Question 13 of 22

Tell me about your current fitness, exercise, movement plan, and any thoughts around it? Please be as specific as possible.

Question 14 of 22

What are your fitness and workout goals? Please be as specific as possible.

Question 15 of 22

Describe your most common meal and eating habits. Breakfast? Lunch? Snacks? Dinner? Are you happy or looking for changes? Please be as specific as possible.

Question 16 of 22

Do you cook regularly?

(Select all that apply)
A

Yes, frequently

B

Occasionally

C

No, I don't like cooking

D

Seldom but would if I had a plan

Question 17 of 22

Describe your thoughts and consumption of Sugary foods? Do you have a sweet tooth? Please be as specific as possible.

Question 18 of 22

Do you consume alcohol, and your thoughts and experiences around alcohol? Please be as specific as possible.

Question 19 of 22

If you do consume alcohol, would you be interested in participating in or learning more about - Taking a Break, Dry January, Dry July, Sober October, etc. 

Question 20 of 22

Do you have a spiritual practice? Attend church regularly? Have a strong "Community" you spend time with? What does it consist of?

Question 21 of 22

Do you ever struggle with any form of anxiety, worry, emotional or mental distress? Please share as much as you are comfortable with.

Question 22 of 22

Anything else you would like to share with me?

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