In-person FREE assessment

RE:WILD WITH JC

Menu

Fill out the form below and I'll get you booked in at The Re:Wild Studio in Merimbula, next to 'In the mix Bakery'.

If you're not in the shire and you'd still like to work with me, you can, check out my online form instead!

General Information

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Date of Birth *

Where are you currently based? *

Preferred Consultation Time/Day *

Personal Background

Occupation/Profession *

Typical Daily Work Activities *

desk job, physical labour, etc.

Work Environment *

home office, stand up desk, etc.

How did you hear about me? *

Current Goals and Objectives

What are your Primary Health and Wellness Goals? *

examples: Pain relief, improve fitness, weight, manage stress, improve posture, etc.

Are there any Secondary Goals your want to achieve? *

What Motivates you to achieve these goals? *

What does success look like in the next 6 months? Be as descriptive as possible! *

What does success look like in the next 18 months? Be as descriptive as possible! *

Current Health Status

Describe your daily energy levels *

Great Average Generally low

Current Pain/Injury Details (Location, Type - dull ache, throbbing, etc, When it hurts and Activities that aggravate/relieve it *

Injury History - Be as detailed as possible *

Current Medications - Name, Dosage and Purpose *

Current Supplements - Name, Dosage and Purpose *

Allergies, Sensitives or Chronic Conditions *

Diet and Nutrition

Describe a Typical Day of eating *

Any Specific Dietary Preferences/Restrictions *

Food Allergies or Intolerances *

How would you describe your Digestive Health? *

Pretty Good Regular Bloating Occasional Bloating

How much Water do you drink per day? *

How much Caffeine do you consume per day? *

How much Alcohol do you drink per week? *

How much sugar is in your diet? *

Too much Some No too much

How often do you eat takeaway/pre-packaged foods? *

Daily A couple of times per week Rarely

Have you made any changes to your Eating Habits lately? *

Sleep and Recovery

Describe your Pre-Bedtime Routine *

How many hour of Sleep do you get on average per night? *

Describe the first hour of you morning *

Do you Wake Feeling Rested? *

Most of the time Sometimes Rarely

Do you nap? *

Often Rarely Never

Do you use any Sleep Aids/Trackers? *

Movement and Activity Levels

Describe your current Physical Activity Levels *

Sedentary Slightly Active Active Very Active

What does your current Exercise Routine look like? *

How would you describe your current Posture? *

Terrible Pretty Poor Good Great

Environmental and Social Factors

Describe your Home Environment *

Describe your Work Environment *

Describe your Social Support Network *

Mental Health

Describe your current Mental Health *

Describe your Mental Health over the last 5 years *

How do you Manage your Stress? *

Reproductive Health

Are you pregnant? If applicable *

No Yes I'm trying

Any issues with your Menstrual Cycle? If applicable *

Any Reproductive Health issues? If applicable *

Other

Is there anything else you'd like for me to know before our assessment? *

Submit

© COPYRIGHT 2024. ALL RIGHTS RESERVED.
Re:Wild with JC Pty Ltd 2024

Home
Free Ebooks
Book your FREE assessment
- In-person FREE assessment
- Online via Video FREE assessment
More

Home
Free Ebooks
Book your FREE assessment
- In-person FREE assessment
- Online via Video FREE assessment
More