Integrated and Holistic Client Assessment

Our Client Liaison will be in contact to discuss the results of your assessment and schedule you for service appointments.

Welcome

Hi there! This assessment is designed to understand your current health and wellbeing, so we can recommend the best next steps to help you thrive. Answer honestly—there’s no right or wrong here, only insights to support you better.

When you finish, you’ll receive suggestions for services like nutritional counseling, yoga, mental health therapy, oral health education, or doula/lactation support tailored just for you.

Last Name, First Name

Phone Number

Overall Wellbeing Check-In

1. Over the past two weeks, how often have you felt:

Physical Activity and Energy Levels

3. How often do you engage in any physical activity (e.g., walking, yoga, or sports)?

Daily A few times a week Rarely or never

4. What makes it difficult for you to be active? (Check all that apply):

Lack of time

Lack of motivation

Physical pain

Fatigue

Mark any areas of physical discomfort or pain in your body.

Nutrition and Appetite

5. How would you describe your eating habits?

Balanced and healthy most of the time A mix of healthy and unhealthy meals Poor or inconsistent (e.g., skipped meals, fast food)

6. Do you feel confident in your ability to plan or prepare healthy meals?

Yes, always Sometimes Rarely or never

7. Have you experienced any unexplained changes in appetite recently?

Yes, increased appetite Yes, decreased appetite No noticeable changes

8. Have you experienced any unexplained changes in weight recently?

Yes, increased weight Yes, decreased weight No noticeable changes

Oral Health

Emotional and Mental Health

12. Over the past month, how often have you: (0 = Not at all, 5 = All the time)

Pregnancy, Postpartum, and Lactation

Only answer if you are currently pregnant or postpartum (within the last 12 months).

15. How many weeks pregnant/postpartum are you?

Self-Reflection and Goals

Other:

By submitting this form, I consent to being contacted by a representative of Arabella Wellness Center regarding services, programs, or updates. I understand that my information will be kept confidential, will not be sold, and that I can opt out of communications at any time by notifying Arabella Wellness Center in writing. For more details, please refer to our Privacy Policy.

Your information will be encrypted.

Integrated and Holistic Client Assessment

Our Client Liaison will be in contact to discuss the results of your assessment and schedule you for service appointments.

Welcome

Overall Wellbeing Check-In

Physical Activity and Energy Levels

Nutrition and Appetite

Oral Health

Emotional and Mental Health

Pregnancy, Postpartum, and Lactation

Self-Reflection and Goals

Our Client Liaison will be in contact to discuss the results of your assessment and schedule you for service appointments.

Arabella Wellness Center Inc