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RECHARGE
Health & Wellness
body recharging station
free consultation
First name
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Last name
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Email
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General Wellness and Lifestyle
On a scale of 1-5, how would you rate your current overall wellness? (1=Poor, 5=Excellent
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1
2
3
4
5
What are your top 2–3 health or wellness goals? (Examples: reduce stress, improve sleep, manage chronic pain, boost energy, lose weight, etc.)
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Are there any specific areas of your health you would like to focus on first? (Physical recovery, mental wellness, mobility, immune support, etc.)
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Health History & Current Challenges
Do you have any current or past health conditions we should be aware of?
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Are you currently experiencing any of the following? (Check all that apply)
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Poor Sleep
Chronic Pain
Stress or Anxiety
Low Energy or Fatigue
Inflammation
None of the Above
Sleep
On average, how many hours of sleep do you get per night?
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How would you describe the quality of your sleep? (Restful, light, interrupted, trouble falling asleep, etc.)
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Is improving sleep one of your wellness priorities? (Yes/No)
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Nutrition
How would you describe your current nutrition? (Check any that apply)
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Well balanced and consistent
I try to eat healthy but struggle with consistency
Im not sure where to start
I have specific dietary needs (please list): ___________
Are you interested in receiving nutrition tips or guidance as part of your wellness journey? (Yes/No)
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Yes
No
Exercise & Activity
How active are you currently? (Check one)
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I exercise regularly (3+ times per week)
I’m somewhat active but not consistent
I rarely exercise
What types of physical activity do you enjoy or are interested in? (Walking, yoga, strength training, group classes, etc.)
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Are you looking to add more movement or fitness into your routine? (Yes/No)
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Yes
No
Habits & Stress Levels
On a scale of 1-5, how would you rate your current stress levels? (1=Very Low, 5=Very High)
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1
2
3
4
5
What are your go-to ways of managing stress right now? (Meditation, exercise, social time, etc.)
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Are there any habits you’d like to improve or change? (Better sleep, less screen time, healthier eating, daily movement, etc.)
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Wellness Interests
Which types of therapies sound interesting to you? (Check all that apply—no pressure!)
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Relaxation & stress relief
Pain management
Muscle recovery & performance
Detoxification
Weight loss support
Skin & beauty treatments
General wellness & prevention
Routine & Preferences
How many times per week would you ideally like to visit Recharge?
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Is there anything else you'd like us to know about your wellness journey, challenges, or preferences?
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