Wellness Assessment

GATE: Confirm scope of practice before designing the assessment. Only include sections you are qualified to evaluate.

Phase 2: Assessment Sections

Section 1: Personal Information

## Client Information

Name: _______________
Date: _______________
Date of birth: _______________
Email: _______________
Phone: _______________
Emergency contact: _______________
Emergency phone: _______________

Section 2: Health History

## Health History

**Current medical conditions (check all that apply):**
[ ] Heart disease or cardiovascular condition
[ ] High blood pressure
[ ] Diabetes (Type 1 / Type 2)
[ ] Asthma or respiratory condition
[ ] Joint or bone issues (arthritis, osteoporosis)
[ ] Back pain or spinal conditions
[ ] Thyroid condition
[ ] Anxiety or depression
[ ] Autoimmune condition
[ ] None of the above
[ ] Other: _______________

**Current medications:**
_______________

**Allergies (food, medication, environmental):**
_______________

**Past surgeries or injuries:**
_______________

**Are you currently under a doctor's care for any condition?** Yes / No
If yes, has your doctor cleared you for [exercise / dietary changes]? Yes / No / Not yet

**For women: Are you pregnant or planning to become pregnant?** Yes / No / N/A

**Do you have any physical limitations that affect movement or exercise?**
_______________

Section 3: Lifestyle Evaluation

## Current Lifestyle

**Sleep:**
- Average hours per night: ___
- Sleep quality (1-5, 5 = excellent): ___
- Do you have trouble falling or staying asleep? Yes / No

**Stress:**
- Current stress level (1-10, 10 = extremely stressed): ___
- Top 3 sources of stress: _______________
- How do you currently manage stress? _______________

**Nutrition (typical day):**
- Breakfast: _______________
- Lunch: _______________
- Dinner: _______________
- Snacks: _______________
- Water intake (glasses per day): ___
- Alcohol (drinks per week): ___
- Caffeine (cups per day): ___

**Physical Activity:**
- Current exercise frequency: ___ days/week
- Types of exercise: _______________
- Activity level at work: Sedentary / Lightly active / Active / Very active

**Habits:**
- Do you smoke? Yes / No / Former
- Screen time (hours per day outside of work): ___

Section 4: Goals & Motivation

## Your Goals

**Primary goal:**
_______________

**Why is this goal important to you right now?**
_______________

**What have you tried before to achieve this goal?**
_______________

**What worked? What didn't?**
_______________

**On a scale of 1-10, how ready are you to make changes?** ___

**On a scale of 1-10, how confident are you that you can succeed?** ___

**What is the biggest obstacle you anticipate?**
_______________

**How will you know you have succeeded? What does success look and feel like?**
_______________

**Timeline: When do you want to achieve this goal?**
_______________

Phase 3: Evaluation & Summary

Assessment Summary Template

## Wellness Assessment Summary — [Client Name]

**Date:** [Date]
**Assessed by:** [Your name]

### Key Findings

**Health considerations:**
- [Any conditions or medications that affect programming]
- [Referral needed? Yes/No — to whom]

**Lifestyle strengths:**
- [What they are already doing well]

**Lifestyle areas for improvement:**
- [Sleep, stress, nutrition, or activity gaps]

**Goal alignment:**
- Primary goal: [Goal]
- Readiness level: [X/10]
- Confidence level: [X/10]
- Timeline: [Stated timeline — realistic? Yes/No]

### Recommended Focus Areas (Priority Order)

1. [Focus area 1] — [Why and initial action step]
2. [Focus area 2] — [Why and initial action step]
3. [Focus area 3] — [Why and initial action step]

### Referrals Needed
- [ ] Medical clearance from physician
- [ ] Registered dietitian for [specific concern]
- [ ] Mental health professional for [specific concern]
- [ ] Physical therapist for [specific concern]
- [X] None needed at this time

Reassessment Plan

Schedule reassessments at regular intervals:

• 4-week check-in: Quick progress review, habit adherence, adjust as needed
• 8-12 week reassessment: Full assessment comparison, measure progress toward goals
• Ongoing: Brief monthly check-ins between full assessments

Phase 4: Implementation

Delivery Options

Assessment Checklist

• All sections are appropriate for your scope of practice
• Health history section covers conditions relevant to your service
• Consent and disclaimer are included (see health-disclaimer skill)
• Referral triggers are identified (when to refer to a medical professional)
• Assessment is stored securely and confidentially
• Reassessment schedule is communicated to the client
• Summary is reviewed with the client, not just filed away

Anti-Patterns

• Asking medical questions beyond your scope — if you are not a doctor, do not diagnose. Collect history and refer when appropriate.
• Collecting data and never using it — every question should inform your programming. Remove questions that do not change what you do.
• Skipping the health history — starting a fitness or nutrition program without knowing medical conditions is reckless.
• Not following up on red flags — if a client reports chest pain during exercise or an unmanaged condition, refer them to a physician before continuing.
• One assessment and done — progress tracking requires reassessment. Build it into your process.

Recovery

• Client does not disclose a condition: Include a clause that the client is responsible for disclosing all relevant health information and updating you if their status changes.
• Red flag in health history: Pause programming and require medical clearance. Do not design programs around conditions you are not qualified to manage.
• Client is resistant to the assessment: Explain that the assessment ensures their safety and helps you design the most effective program for them.
• Assessment is too long: Trim to essential sections only. A 30-minute assessment that gets completed beats a 60-minute one that gets abandoned.
• Client goals are unrealistic: Have an honest conversation. Adjust the timeline or reframe the goal to be achievable and measurable.