Wellness form for the 60-day challenge at Harbor Square Athletic Club.

Participant Wellness Info

First Name*

Last Name*

Email*

Do you struggle with any of the following. Yes or No. Please note a "maybe" should be marked with a "yes".

Energy Levels

Yes
No

Sugar and Carb Cravings

Yes
No

Sleep Quality

Yes
No

Bowel Movement Regularity

Yes
No

Mood

Yes
No

Productivity

Yes
No

Clarity of thought

Yes
No

Hunger

Yes
No

Motivation

Yes
No

Gas, Bloating, GI issues

Yes
No

Headaches

Yes
No

Health Habits

Please answer the following questions.

Do you smoke?

If "yes" to smoking, how much?

Rarely/Social Settings
Less than one pack per day
More than one pack per day

Do you drink alcohol?

If "yes" to drinking alcohol, how much?

Rarely/Social Settings
One to two beverages per week.
Three to four beverages per week.
Five or more beverages per week.

How many hours of sleep do you get each night?

Are you rested and rejuvenated when you wake?

Do you have trouble falling asleep at night?

Do you have specific wellness goals for this challenge (i.e. reduced stress, better sleep, more mindfulness, etc.)?

What type of setting do you eat the following meals in?

Check all that apply.

BREAKFAST

In front of television
with groups of people
while at work
with music playing
alone
reading
on the go

LUNCH

In front of television
with groups of people
while at work
with music playing
alone
reading
on the go

DINNER

In front of television
with groups of people
while at work
with music playing
alone
reading
on the go

Do you plan your meals?

Generally, how do you feel after your meals?

Tired
Bloated
Satisfied
Still Hungry
Overly Stuffed
Gassy
Guilty
Energized

On a scale of 1 to 10; 1 being no-stress, and 10 being, "incredibly, almost unbearably" stressed; please let us know how you rank in the following categories.

Career Life

Family Life

Personal Life

On the road to
health & wellness.

Complete the form below.

Participant Wellness Info

Do you struggle with any of the following. Yes or No. Please note a "maybe" should be marked with a "yes".

Health Habits

What type of setting do you eat the following meals in?

On a scale of 1 to 10; 1 being no-stress, and 10 being, "incredibly, almost unbearably" stressed; please let us know how you rank in the following categories.

On the road to health & wellness.

Complete the form below.

Participant Wellness Info

Do you struggle with any of the following. Yes or No. Please note a "maybe" should be marked with a "yes".

Health Habits

What type of setting do you eat the following meals in?

On a scale of 1 to 10; 1 being no-stress, and 10 being, "incredibly, almost unbearably" stressed; please let us know how you rank in the following categories.

On the road to
health & wellness.