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RECHARGE
Health & Wellness
body recharging station
FREE CONSULTATION
First name
Last name
Email
General Wellness and Lifestyle
On a scale of 1-5, how would you rate your current overall wellness? (1=Poor, 5=Excellent
1
2
3
4
5
What are your top 2–3 health or wellness goals? (Examples: reduce stress, improve sleep, manage chronic pain, boost energy, lose weight, etc.)
Are there any specific areas of your health you would like to focus on first? (Physical recovery, mental wellness, mobility, immune support, etc.)
Health History & Current Challenges
Do you have any current or past health conditions we should be aware of?
Are you currently experiencing any of the following? (Check all that apply)
Poor Sleep
Chronic Pain
Stress or Anxiety
Low Energy or Fatigue
Inflammation
None of the Above
Sleep
On average, how many hours of sleep do you get per night?
How would you describe the quality of your sleep? (Restful, light, interrupted, trouble falling asleep, etc.)
Is improving sleep one of your wellness priorities? (Yes/No)
Nutrition
How would you describe your current nutrition? (Check any that apply)
Well balanced and consistent
I try to eat healthy but struggle with consistency
Im not sure where to start
I have specific dietary needs (please list): ___________
Are you interested in receiving nutrition tips or guidance as part of your wellness journey? (Yes/No)
Yes
No
Exercise & Activity
How active are you currently? (Check one)
I exercise regularly (3+ times per week)
I’m somewhat active but not consistent
I rarely exercise
What types of physical activity do you enjoy or are interested in? (Walking, yoga, strength training, group classes, etc.)
Are you looking to add more movement or fitness into your routine? (Yes/No)
Yes
No
Habits & Stress Levels
On a scale of 1-5, how would you rate your current stress levels? (1=Very Low, 5=Very High)
1
2
3
4
5
What are your go-to ways of managing stress right now? (Meditation, exercise, social time, etc.)
Are there any habits you’d like to improve or change? (Better sleep, less screen time, healthier eating, daily movement, etc.)
Wellness Interests
Which types of therapies sound interesting to you? (Check all that apply—no pressure!)
Relaxation & stress relief
Pain management
Muscle recovery & performance
Detoxification
Weight loss support
Skin & beauty treatments
General wellness & prevention
Routine & Preferences
How many times per week would you ideally like to visit Recharge?
Is there anything else you'd like us to know about your wellness journey, challenges, or preferences?
Submit
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