Wellness Foundation

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Wellness Challenge 360°
Health Questionnaire

Download Checklist and Physician's Consent Form

Please submit this form in advance of your first WC 360° session.

* Indicates required fields

* First Name:
* Last Name:
* Email Address:
* Date of birth (mm/dd/yyyy):
* Gender
* Place of Employment
* Job Title
* Your height Feet:    Inches:
* Have you taken WC 360° before? Yes    No
* How did you hear about WC 360°?
If your doctor referred you, please provide his or her name.

Have you previously tried another program to improve your health? If so, please describe it.
If you have already made changes to your diet that coincide with the recommendations of WC 360°, please provide the approximate date that you began to make those changes. (mm/dd/yyyy)    / 

* List your main health concerns. Please include all currently diagnosed conditions.

Physical Conditions

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


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.)


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


* 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?


Consider the wellness goals you want to accomplish in the course of the 7-week program. Please choose from the following and indicate the specifics of your goals. For example, if weight loss is one of your goals, check weight loss and indicate how many pounds you would like to lose on the line that follows.

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

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