Wellness Coaching RequestOracle Peptides2026-01-04T23:14:09-06:00

Wellness Coaching Request

Name(Required)

First Last

Email(Required)

Phone(Required)

I want to address the following areas with my coach(Required)

Select those that apply

How often are you physically active, on average, per week?(Required)

6-7 times per week

4-5 times per week

2-3 times per week

1-2 times per week

(physical activity is defined as continuously moving your body 15 minutes or more)

Rate the importance to me of regular physical activity:(Required)

Please enter a number from 1 to 10.

1 (Not at all important) and 10 (Most important thing in my life)

My readiness to make changes or improvements to reach or sustain regular physical activity:(Required)

I am already maintaining good physical activity levels consistently (6 mos. +)

I recently starting working on this

I am planning on changing this month

I am planning a change to start in the next 6 months

I have no present interest in making a change

Do you have any limitations in exercising?(Required)

Yes

How often do you eat breakfast (more than just a roll and cup of coffee)?(Required)

I eat breakfast every day

I eat breakfast most mornings

I eat breakfast 2-3 times per week

I seldom or never eat breakfast

How often do you eat “junk” snack foods between meals?(Required)

Three or more times per day

Eat mostly the high fat foods

Eat both about the same

Eat mostly low fat foods, some high fa

Eat only low fat foods

Ex. Pastries, candy, ice cream, cookies

How many servings of fruits and vegetables do you eat daily?(Required)

One or less

Two daily

Three daily

Four daily

Five or more

A serving is: 1 cup fresh, ½ cup cooked, 1 medium fruit, or ¾ cup juice

How many 8 ounce glasses of water do you drink on average per day?(Required)

None

1-2 glasses

3-5 glasses

6-8 glasses

How many 8 ounce glasses of soft drinks do you drink on an average per day?(Required)

Seldom or never

1-2 glasses

3-5 glasses

5 or more

Rate the importance to me of consuming healthy food and drinks most of the time:(Required)

Please enter a number from 1 to 10.

1 (not very important) and 10 (very important)

How well do you feel you are coping with your current stress load?(Required)

Feeling unable to cope anymore

Coping fairly well

Coping very well

How many hours of sleep do you get on average?(Required)

Less than 6

6-7 hours

7-8 hours

During the past 4 weeks, to what extent have you accomplished less than you would have liked in your work or other daily activities as a result of emotional issues, such as feeling depressed or anxious?(Required)

1. None of the time 2. A little of the time 3. Some of the time 4. A good bit of the time 5. All the time

The next questions are about how you feel things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

How much of the time during the past four weeks have you felt calm and peaceful?(Required)