Wellness Center – Wellness Assessment

First Name(Required)

Last Name(Required)

Phone

Age Group

What is your gender identity?

Please list how you identify if applicable.

How did you hear about the Health Wellness Center?

Taking everything into consideration, during the past week how satisfied have you been with your……?

	Very Poor	Poor	Fair	Good	Very Good
Physical Health
Mood
Work
Household Activities
Social Relationships
Family Relationships
Leisure Time Activities
Ability to function in daily life
Sexual drive, interest, and/or performance
Economic Status
Living or Housing Situation
Ability to get around physically without feeling dizzy or unsteady or falling
Your vision in terms of ability to do work or hobbies
Overall sense of well being
Medication (if not taking any pick 5)
Overall life satisfaction and contentment during the past week

What aspect(s) of your wellness would you like to improve?

Mind/Body- Balancing your physical and mental wellbeing

Knowledge- Gaining information and resources to strengthen, support, and enhance your health.

Connectedness- Promoting community engagement to decrease isolation.

Spirtuality- Embracing the spiritual diversity to feed the deepest needs of oneself.

Environmental- Including nature and beauty as essential needs for wellbeing.

Economic- Incorporating value-based financial wellness, education, and support.

On average, what is your physical pain level on a scale of 1-10?

What was your highest physical pain level in the last 7 days?

What is your stress level today on a scale of 1-10?

What was your highest stress level in the last 7 days?

Do you feel like you get enough sleep at night?

Do you use Tobacco products?

Yes

what form of delivery do you use?

Cigarettes

Vape

Dip

Pipe

Smokeless

Cigars

do you wish to have support on reducing or stopping your usage?

Yes

If you were to consume an alcoholic beverage, on average, how many alcoholic beverages would you say you consume in a week? (A standard drink is equivalent to 12oz of beer, 5oz of wine, and 1.5oz of liquor)

Would you like assistance/support with reducing or stopping your alcohol use?

Yes

Do you use any illicit drugs?

Yes

If yes, would you like assistance/support in reducing or stopping your drug use?

Yes

N/A

Do you have anything you wish to add?

Corporate headquarters

6363 De Zavala Road

San Antonio, Texas 78249

(833) 828-6439