100 Days of Wellness

Lifestyle Questionnaire

 

General Instructions: Please fill out this form as completely as possible. If you have questions, do not guess. Please ask for assistance.

Today's Date
Today's Date
Name *
Name
Choose your path *
Set your goal *
Choose your energy source *
How often do you currently workout? *
Does your job require physical activity? ie. lifting, walking *
How confident are you that you can complete the challenge? *
How confident are you that you can complete the challenge?
Rate the following questions based on importance (1 = low importance, 5 = high importance)