ASSESSMENT | Vitality Connect

Please be honest with your answers. Should you not want to answer anything specific please leave it blank.

At Vitality Connect, we offer personalized wellness coaching for individuals seeking deeper guidance and support on their health journey. Our coaching is rooted in holistic, science-backed approaches, focusing on nutrition, movement, mindset, and functional health insights.

Please complete this questionnaire only if you are interested in personalized coaching. If you are not seeking coaching at this time, you are welcome to reach out to us with general inquiries or browse our wellness resources.

Section 1: Personal Information

First name

Last name

Email

Age

Gender

Female

Male

Weight in kg

Height in cm

Primary Health Goal (Weight Loss, Muscle Gain, Stress Management, Overall Health, Specific Condition Management)

Section 2: Medical and Health History

Do you have any diagnosed medical conditions? (e.g., Diabetes, Hypertension, Thyroid Disorders, MTHFR Gene Mutation, etc.)

Are you currently taking any medications or supplements? (List medication type and/or supplementation)

Do you have a family history of chronic illnesses or genetic conditions?

Have you ever had blood tests for the following? (Tick all that apply)

Complete Blood Count (CBC)

Hormone Panel (e.g., Thyroid, Cortisol, Estrogen/Testosterone)

Vitamin & Mineral Levels (e.g., B Vitamins, Vitamin D, Magnesium, Zinc)

Inflammatory Markers (e.g., CRP, ESR)

Methylation Panel (e.g., MTHFR, MTRR, COMT)

Do you have regular check-ups with a healthcare professional?

Yes

No

Only when unwell

Section 3: Nutrition Habits

How would you describe your current diet? (e.g., Balanced, High-Protein, Vegetarian, Vegan, High-Sugar, Processed Foods)

Do you have any food allergies or intolerances?

How many meals do you eat per day?

Do you frequently consume processed or fast foods?

How much water do you drink daily?

Do you consume caffeinated beverages? (e.g., Coffee, Energy Drinks)

Do you consume alcohol? If yes, how frequently?

Section 4: Fitness and Activity Levels

How often do you exercise per week?

Sedentary

1-2 times per week

3-5 times per week

Exercise regularly

What type of exercise do you primarily do? (e.g., Cardio, Strength Training, Yoga, Walking)

Do you have any physical limitations or injuries?

Do you use fitness trackers or apps to monitor your activity?

What are your fitness goals? (e.g., Weight Loss, Build Muscle, Improve Endurance)

Section 5: Mental and Emotional Health

How would you rate your current stress levels? (Low, Moderate, High)

What stress?

Somethings stress me out

It's too much

How do you manage stress? (e.g., Exercise, Meditation, Therapy, Unhealthy Coping Mechanisms)

Do you experience mood swings, anxiety, or depressive symptoms frequently?

Do you get enough sleep? (Hours per night on average)

How would you describe your general mindset? (e.g., Positive, Neutral, Negative)

Do you feel motivated to make positive lifestyle changes?

Section 6: Lifestyle and Environment

Do you work in a high-stress environment?

Yes

No

At times

Do you spend time outdoors regularly?

Yes

No

Whenever I can

Do you have supportive relationships (family, friends, colleagues)?

How often do you take time for self-care or relaxation?

Do you smoke or use recreational drugs? (no judgement)

Section 7: Wellness

What are your short-term wellness goals (3-6 months)?

What are your long-term wellness goals (1 year+)?

Is there anything else you'd like us to know about your health, fitness, or wellness journey?

Thank you for completing this questionnaire!

Your responses will help us create a personalized nutrition, fitness, and wellness plan tailored specifically to your needs. Based on your results, we may also recommend follow-up consultations with a carefully selected Wellness Coach for targeted testing or further support.

Would you like us to schedule an initial consultation to review your results and discuss the next steps?