Wellness Assessment

Where are you on your health journey?

Ready to take control of your wellness? This short assessment will help us understand your goals, challenges, and where you need the most support. By gaining clarity on your current habits and mindset, we can create a customized approach to help you build sustainable, lasting change.

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Full Name *

Email *

Phone

Do you have any chronic illnesses or conditions? *

Chronic Illnesses / Conditions

Are you currently under the care of any healthcare providers? *

Healchcare Providers

for Describe routine?

What are the top three health challenges you are facing right now? *

What medications or supplements are you currently taking?

What are your top three health and wellness goals? *

How confident are you in your ability to make changes to improve your health? *

What would success in this program look like for you? *

Describe your energy levels on an average day *

How many hours do you sleep per night?

Do you have a regular exercise routine? *

Exercise Routine

What do you typically eat in a day? *

Do you currently have any self-care practices? *

Self-Care Practices

How would you rate your stress levels? *

What are the main sources of stress in your life?

Work or career pressures
Family responsibilities
Health concerns (personal or loved ones')
Financial challenges
Lack of time for self-care
Relationship difficulties
Unhealthy lifestyle habits (poor sleep, diet, etc.)
General anxiety or feeling overwhelmed

Do you practice any mindfulness or relaxation techniques (e.g., meditation, yoga)? *

Relaxation Techniques

Do you have a support system (e.g., family, friends, community) that helps you with your wellness journey? *

Why do you feel now is the right time to begin a coaching program? *

Are there any obstacles or challenges that might prevent you from fully committing to this program?

Is there anything else you would like me to know about your health, goals, or challenges?

Touch of Health with Marisa Herskovitz NBC-HWC provides expert virtual health & wellness coaching, guiding you toward sustainable lifestyle changes for lasting well-being.

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