Well Being Questionnaire "*" indicates required fields Step 1 of 15 6% So, you took the plunge and hit the ‘take my questionnaire’ button and now you are wondering what you are in for… To answer that question, you are in for taking the best step forward on your journey to a lighter, brighter, healthier you, that’s what! I am so glad you've joined me on this first step, and I can’t wait to share your what your results say about you. These questions are personal and are designed to give me the best overview of your health and wellness status as it stands right now. They also allow me a bit of insight as to whereabouts on your health journey you are starting. You can answer as many of them, or as few of them, as you feel comfortable to do, just remember though that the more information that I gain from you, the more value I can provide when we first chat. The questions follow Mason Durie’s ‘Te Whare Tapa Wha’ model of health where we acknowledge the importance of all aspects of health (physical, mental, family/ social, and spiritual cornerstones) as being equally important for your overall health. You may need to allow for 10 – 15 minutes of your time to complete this questionnaire, so do it at a time when you are relaxed, comfortable and don’t have to think about anything else. Please note too, that your privacy is very important to me, and I do not share your results are not shared with anyone other than you and I. Now, if you are ready, let’s get started!GeneralWhat is your name?* First Last What do you prefer to be called? First What is your year of birth? Month Day Year What gender are you? Or how do you identify? What is your height? (mm)What is your weight? (Kg)What is your ethnicity? In which town and country do you live? Town / City AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you come across this questionaire? laurafourie.com Facebook Instagram LinkedIn Email Other SleepHow many hours a night do you sleep?What time do you go to bed?Please use the 24hr format ie: 2030What time do you wake up?Please use the 24hr format ie: 0800Do you wake up during the night?YesNoHow many times?Why?Do you wake up feeling:RestedStill tired WorkDo you work?YesNoWhat work do you do?What time of day do you work?DaytimeEveningsShiftsWhat type of work mostly is it?SedentaryActiveBothHow many hours do you work per week?How do you fill in your day, do you receive financial support from somewhere, and is it enough? SmokingDo you smoke?YesNoHave you ever tried to cut back or quit?YesNoWhen and Why?Are you exposed to any second-hand smoke?YesNoHow often? Where? How do you feel about smoking? ChemicalsAre you exposed to any toxic substances in and around your home/workplace? Explain. AlcoholDo you drink alcohol?YesNoWhen do you drink? How many standard drinks per week?What do you drink?Does drinking impact your life in any negative way?YesNoHow has it impacted you?Have you ever tried to cut back or quit? When? Why?How do you feel about alcohol? Exercise / MovementHow do you feel about exercise?Do you do any exercise at the moment?YesNoWhat do you do, how many times a week and for what length of time?Why?Did you used to do any exercise previously? Explain.Would you comfortably, without restriction, be able to climb a flight of stairs? Explain.Would you comfortably, without restriction, be able to run the length of a football field? Explain. Fluid IntakeDo you drink any water during the day?YesNoHow much water do you drink? When do you drink it? What stops you from drinking water? Do you drink tea/ coffee?YesNoHow many cups do you drink per day? How do you take it? Milk Cream Black Sugar Syrups Other Do you drink fizzy drinks and/or juiceYesNoWhich ones?How many litres of fizzy drinks and/or juice do you drink per day?An average can size is 375ml Food IntakeDo you eat regularly?YesNoWhat is regular to you?How often and at what times would you generally eat?Do you cook meals/ prepare food at home?YesNoWhat kind of meals do you prepare/ eat?Do you eat pasta, rice, taro, cassava, tapioca, bakery foods, breads, cakes, sweets, and other treats?YesNoTell me moreHow often per week do you eat out/ get takeaways?What typically would you choose to buy/ eat?Do you eat much fruit?YesNoWhich fruit, how many pieces and how often do you eat them?Do you eat many vegetables?YesNoWhich vegetables, how many pieces and how often do you eat them?Do you crave sugar/ carbs?YesNoWhen do you notice these cravings?Do you get excessively hungry or hungry later at night?YesNoIs it true to say that you do not feel hungry at all?YesNo Physical HealthDo you have high blood sugar or cholesterol?YesNoWhat are your latest blood results for these?If unsure, have you considered getting these checked by your doctor?When was your last test for these? Month Day Year Do/ have you experienced bloating, drops in energy levels, sudden weight gain? Explain.Are you currently on any medication?YesNoPlease explain Family / Social HealthAre you in a relationship?YesNoHow would you describe it?eg. supportive, caring, challengingYou live:TogetherSeperatelyDo you live on your own, or with others? ExplainDo you have any children?YesNoHow many and how old are they?Do they live with you, or you with them?They live with meI live with themDo you have any concerns for them?Are you trying for children? Are you experiencing any issues with this?How often each week, would you socialise with family or friends?How often each week, would you attend religious or social gatherings?Does anyone in your immediate or extended family have any of the following: Pre-Diabetes Diabetes Cholesterol Kidney Disease Cancer(s) High Blood Pressure Cardiovascular Disease Gout Mental HealthHow would you rate your experience of stress in your life (this could include work, relationship, social, financial etc)?123456789101 is no stress and 10 is max stress.Do you experience anxiety or nervousness?YesNoHow often do you experience this? What brings this about for you?Have you sought support in managing these feelings?Do you experience feelings of sadness or depression?YesNoHow often do you experience this? What brings these feelings on for you?Have you sought support in managing these feelings? COVIDHow have you felt you have managed the Covid pandemic?Have you been directly affected by Covid on a physical/ emotional/ mental/ spiritual level? Explain.Have you got any fears around Covid and its impact on you or your loved ones? Explain. Medical Practitioners CareAre you currently seeing any Medical Practitioners for any particular health issues?YesNoWhat treatment/ care are you currently undergoing?Has your Medical Practitioner expressed any concerns for you or health?Do you have any concerns for your health at this time? And Finally:Congratulations, you made it to the end of the questions, and I bet you are keen to hear what they have to say about you and your journey. Please jot down your email address here so that I can be in touch with you to book in your free ‘Discovery Call’ where we can chat about your answers. I am so looking forward to hearing from you! Bye for now!Email*
