Wellness Questionnaire

  • Please answer each question and provide additional details as requested.
    All information is confidential.

    Please contact us if you have any questions.

    Thank you for your time and assistance.



    ~Jeff Kildahl, CWC | SNS | CSCS | BMS | METS | ND | PhD
    Westerly, RI
    Seattle, WA
    401.207.4215 ~ m

    The Wholistic Edge®
    Creator and President

    Snowshoe Magazine
    Wellness Editor

  • Personal Information

  • Lifestyle

  • This section will add clarity to the primary areas you desire to change.
  • Foundation

  • Career | Occupation | Profession

  • Self-Actualization

  • Health | Wellness

  • Please be advised as your ally I may refer you to other practitioners for expertise or treatment in said disciplines. Please convey information below to help me understand your aspirations and any challenges on your path to optimal health and self-actualization.
  • Stages of Readiness

  • 1~List five behaviors you would like to change;
    2~Identify your readiness level;
    3~Add comments
  • Additional Information