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Wellness Challenge 360° Health Followup

Congratulations on completing week 6! Soon you will celebrate together at graduation. Please take a few moments to complete this final health questionnaire so that you can compare your health and well being before WC 360, and after. Don't forget, WC 360 is a journey and not a destination! Think about how to carry your wellness goals into the next weeks, months and years. Please get your final labs done now, so that they are back before graduation. You will need the final health questionnaire filled out and your lab results back in order to get your $50 refund.

* Indicates required fields

* First Name:
* Last Name:
* Email Address:

* List all changes in medication you have made:


Physical Conditions

* Select the number, on a scale of 0 to 10 (0 never and 10 always) that represents your experience.

Headaches

Sore or stiff muscles or joints

Back pain

Heartburn, acid reflux

Gastrointestinal discomfort

Skin problems

Fatigue, lack of energy

Food cravings (sugar, fat, salt etc.)

Eat to reduce stress

Lack of concentration

Difficulty sleeping

Depression, unpleasant mood


Quality of Life

* Which best describes how you perceive your health?

* How much control do you feel you have over your health? (On a scale from 0-10, 0 being no control and 10 being total control)


WFPB Diet:

A low-fat, whole foods, plant-based diet emphasizes fruits, vegetables, and starches (beans, lentils, and whole, intact grains) and, at the same time, limits or eliminates animal products (all meats, including chicken and fish, dairy, and eggs) and highly refined foods, such as white flour, refined sugar, and oil. About 80% of calories come from carbohydrates, 10% from fats, and 10% from protein.

* How closely does your diet resemble a WFPB diet? (0-10, 0 being not at all resembling a WFPB diet and 10 being strictly resembling.)


Exercise

* How many minutes per week do you engage in exercise?


Stress

* On a scale of 0-10 (with 0 showing the least stress and 10 the most) how would you rate the stress level in your life?


Accomplishments

To what extent did you accomplish your wellness goals? For example, if one of your goals was weight loss, check weight loss and indicate how close you came to achieving the goal on the line that follows. (We realize that being able to evaluate your goals may depend on knowing your completion lab results. If you don’t know those results yet, note that you are waiting for lab results.)

Weight loss:
Reduce cholesterol:
Reduce glucose:
Reduce physical ailments:
Reduce food cravings:
Reduce stress:
Increase energy:
Other:

Looking Forward: Future Goals

* Which wellness goals would you like to achieve in the next six months? As at the beginning of the program, be realistic and be as specific as possible.

* While some folks graduate from WC 360° and are able to maintain or go on to have more health success, most need at least a little support. Consider that you won't be meeting as a small group each week. What would help you as you continue to follow the guidelines of WC 360°?


About WC 360°

* Score each item on a scale of 0 to 10 (0 no value, 10 very valuable).

Food Demonstrations

Overall benefit to you

WC 360° Jumpstart Guide

Mindfulness tools

Facilitator instruction

Group support

WC 360° Guidebook

Accountability partners

Facebook group

Weekly workout videos

Yoga videos


* Would you recommend WC 360° to a friend or family member?

Please briefly describe why you selected the above option.


Feedback

Please share anything else you think would help us to improve the program.


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