WELLNESS CHECKLIST
WELLNESS CHECK QUESTIONNAIRE

Thank you for taking the time to complete the Wellness Check Questionnaire. Please fill out the following questions to the best of your ability. When completed, you'll be able to print your results and take them to your practitioner for further evaluation.

Please note: the information you provide is confidential, and we do not track, save or share your responses.

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STEP 1 OF 4
  • A Rare / Never
  • B 1-3 times a month
  • C 1+ times per week / New condition
    •  
      A
      B
      C
    • 1. Stomach Discomfort
    • 2. Lung Congestion
    • 3. Dehydrated or thirsty
    • 4. Gas-type indigestion
    • 5. Circulation problems
    • 6. Intestinal upsets
    • 7. Yeast infections
    • 8. Burping or belching
    • 9. Hoarseness or laryngitis
    • 10. Swollen feet
    • 11. Fats hard to digest
    • 12. Sweat easily
    • 13. Alcohol intolerance
    • 14. Constipation
    • 15. Cold sores
    • 16. Nose discharge or dryness
    • 17. Bladder problems
    • 18. Earaches
    • 19. Restless sleep
    • 20. Abdominal bloating
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