Name *

First Name

Last Name

Phone

(###)

###

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1. Biggest Challenge: What is your biggest challenge in managing your health and well-being? *

(Select one)

Balancing work and personal responsibilities

Feeling too overwhelmed to take action

Lack of time for self-care

Not knowing where to start

Feeling like nothing will work for me

2. Daily Life: How often do you feel overwhelmed or out of control? *

Rarely

Occasionally

Often

Almost every day

3. Current Symptoms: Which of the following symptoms do you experience regularly? *

(Select all that apply)

Anxiety

Insomnia

Fatigue

Weight gain

Physical pain or discomfort

4. Health Goals: What does “living a healthier lifestyle” mean to you? *

(Select all that apply)

Feeling more calm and in control

Improving physical health (weight, sleep, energy...)

Reducing stress and anxiety

Building healthier habits

5. Barriers to Change: What stops you from starting or maintaining healthier habits? *

(Select all that apply)

Lack of time

Feeling too overwhelmed

Not knowing what to do

Fear it won't work

6. Beliefs About Change: Do you believe small, consistent changes can improve your health and well-being? *

Yes, absolutely

Maybe, but I'm not sure how

No, I don't think it will work for me

7. Motivation and Support: What would help you prioritize your well-being? *

(Select all that apply)

Short, simple practices I can do at home

Accountability or support from others

Tools or resources to guide me

More time in my day

8. Time for Self-Care: How much time could you realistically dedicate to self-care each day? *

Less than 5 minutes

5 - 10 minutes

10 - 20 minutes

20 - 30 minutes

More than 30 minutes