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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)

What are your top 2–3 health or wellness goals? (Examples: reduce stress, improve sleep, manage chronic pain, boost energy, lose weight, etc.)

Are there any specific areas of your health you would like to focus on first? (Physical recovery, mental wellness, mobility, immune support, etc.)

Health History & Current Challenges

Do you have any current or past health conditions we should be aware of?

Are you currently experiencing any of the following? (Check all that apply)

Sleep

On average, how many hours of sleep do you get per night?

How would you describe the quality of your sleep? (Restful, light, interrupted, trouble falling asleep, etc.)

Is improving sleep one of your wellness priorities? (Yes/No)

Nutrition

How would you describe your current nutrition?

Well balanced and consistent

I try to eat healthy but struggle with consistency

I'm not sure where to start

I have specific dietary needs

Dietary Needs:

Are you interested in receiving nutrition tips or guidance as part of your wellness journey? (Yes/No)

yes

no

Exercise & Activity

How active are you currently? (Check one)

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.)

Are you looking to add more movement or fitness into your routine? (Yes/No)

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)

What are your go-to ways of managing stress right now? (Meditation, exercise, social time, etc.)

Are there any habits you’d like to improve or change? (Better sleep, less screen time, healthier eating, daily movement, etc.)

Wellness Interests

Which types of therapies sound interesting to you? (Check all that apply—no pressure!)

Routine & Preferences

How many times per week would you ideally like to visit Recharge?

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

RECHARGE
Health & Wellness

body recharging station

General Wellness and Lifestyle

Health History & Current Challenges

Sleep

Nutrition

Exercise & Activity

Habits & Stress Levels

Wellness Interests

Routine & Preferences

RECHARGE Health & Wellness

body recharging station

General Wellness and Lifestyle

Health History & Current Challenges

Sleep

Nutrition

Exercise & Activity

Habits & Stress Levels

Wellness Interests

Routine & Preferences

RECHARGE
Health & Wellness