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THE POWER WITHIN 333

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CLIENT CURRENT LIFESTYLE
QUESTIONNAIRE

Personal Information

First name*

Last name*

Email*

Birthday*

Phone*

Occupation

Physical Health

How would you describe your current physical health? *

Excellent

Good

Fair,

Poor

How often do you exercise per week? *

Never

1-2 times

3-4 times

5 times or more

Do you have any chronic health conditions or medical concerns?

Are you currently on any medication?

What types of physical activities do you engage in?

Do you have any physical limitations or injuries?

Nutrition

How would you describe your current diet? *

Balanced

High in processed foods

Vegetarian

Vegan

Other

Do you have any dietary restrictions or allergies?

How many main meals do you eat per day? *

1

2

3

Do you consume snacks in between meals?

How much water do you drink daily? *

Less than 1 litre

1 to 2 litres

More than 2 litres

Do you consume alcohol or caffeine?

Mental Health

How would you describe your current mental health? *

Good

Fair

Poor

Do you experience stress regularly?

How do you typically manage stress? *

Do you have any mental health concerns or conditions? *

Do you practice mindfulness or meditation?

Spiritual Wellness

Do you have a regular spiritual practice? *

How important is spirituality in your daily life? *

Very important

Somewhat important

Not important

Do you feel connected to a higher power or inner self? *

Have you ever experienced energy healing or other spiritual wellness practices?*

How would you rate your love for yourself? *

Excellent

Good

Fair

Poor

Can you describe to me what self-love means to you? *

Do you know what your purpose is in life and if not, would you want to find out? *

Lifestyle and Daily Routine

Describe a typical day in your life?*

How many hours do you work a week?*

How many hours of sleep do you get per night?*

Do you have a consistent sleep schedule?

Yes

No

How do you spend your free time? (e.g., hobbies, social activities, relaxation)*

Do you feel you have a good work-life balance? *

Goals and Aspirations

What are your primary health and wellness goals? *

Weight loss

Increased energy

Stress reduction

Other

What motivates you to achieve these goals?*

What obstacles have you faced in the past when trying to achieve your wellness goals?*

What areas of your life do you feel need the most improvement? *

Physical

Mental

Emotional

Spiritual

What do you hope to gain from working with a Mind, body and Soul Guide?*

Additional Information

Is there anything else you would like to share about your health and wellness journey?

Are there specific areas or topics you would like to focus on during our sessions?

What would you say your passion is or what you are passionate about?

Consent and Agreement

Do you consent to share this information with your Mind, Body & Soul Guide to create a personalized plan for you? *

Yes

I agree to the terms and conditions for the Mind, Body and Soul Guidance Package*

Yes

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CLIENT CURRENT LIFESTYLE QUESTIONNAIRE

Personal Information

Nutrition

Mental Health

Spiritual Wellness

Lifestyle and Daily Routine

Goals and Aspirations

Additional Information

Consent and Agreement

CLIENT CURRENT LIFESTYLE
QUESTIONNAIRE