Your Wellness Assessment Form

Welcome to your
Wellness Self-Assessment &

Congratulations on taking this important step!

STEP ONE
Completing your Assessment

Option one:
Complete your Wellness Assessment online easily when you click the button below.

When you're finished, click "submit" to share your answers and watch for an email invitation about STEP TWO, scheduling and completing your complimentary Wellness Consultation Planning Session with Dawn.

WELLNESS ASSESSMENT (Online Form)

Option two:
I've included a printable "for your eyes only" version of the Wellness Assessment. Click below to get the pdf document to complete. You will not receive the full complimentary Wellness Consultation mentioned above unless you complete and submit the online form above.

Wellness Assessment (printable form)

Planning for Success

STEP TWO

Your Wellness Planning Consultation

What to Expect:

Email one - You'll receive an email with instructions for scheduling your complimentary consultation soon after completing the online assessment.

Email two - After your consultation call is scheduled and prior to the meeting/call, you'll receive a confirmation email with the Zoom link that you can use for the video call at the scheduled time.

During our time together - I'd like to spend a few minutes reviewing your Wellness Assessment and top areas of concern. Then I'll share about what I can offer and some suggestions for putting together your personalized 30-60-90 day Wellness Plan. If you see anything you'd like to purchase I can help you with that. If not, that's totally cool. How does that sound?

Note: If you've completed the printable version of the Wellness Assessment and decide you want to also complete the online version (a bit shorter but basically the same) feel free to do so. It shouldn't take long at all after completing the print version already.

Remember, the journey of a thousand miles starts with one step. Congrats on getting started on your new Wellness Journey!

Online Wellness Assessment Form

Please score the items below with the following scale..
Never = 0. Occasionally = 1. Often = 2. Almost Always = 3

After you finish your assessment click the SUBMIT button.

Then watch for your email over the next 48 hours regarding your complimentary Wellness Planning Consultation.

*Remember that this is not a diagnostic tool and nothing included is intended for medical diagnosis or treatment. This assessment form is provided as a self-reflective exercise. Any information contained herein or additional information presented is for instructional and educational purposes.

Poor concentration or memory*

Cold hands and feet*

Frequent fried foods*

Food allergies / Difficulty digesting certain foods*

Heavy coating on tongue*

Belching, gas and/or discomfort after meals*

Less than two (2) bowel movements per day*

Feeling drained*

Express emotions in unhealthy ways*

Anxiety, irritable, moody, or feeling down*

Feeling like life has little or no purpose*

Crave or consume sweets, salty food, junk food*

Monthly female issues or low sex drive*

Restless sleep or lack of sleep*

Puffiness under eyes*

Frequent or painful urination / urinary issues*

Diet high meats and grains*

Sore, painful or weak joints / bones*

Frequent illness (more than twice per year)*

Frequent use of antibiotics*

Less than three servings of fruits and vegetables per day*

Stressful lifestyle*

Complexion or other skin issues*

Rashes, lesions or bruise easily*

Lack of energy or chronic fatigue*

Exercise less than two (2) times per week*

Swelling or inflammation*

Unexplained chronic issues (headache, skin, etc.)*

Brittle nails or dry/brittle hair*

Smoker / regularly consume alcohol *

Tremors, muscle cramps or spasms*

Sedentary lifestyle*

Diet high in caffeine*

Numbness or tingling*

Hot flashes, sweats, irregular body temperature*

Exposure to air pollutants*

Heavy mucus production or congestion*

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2025 (C) Dawn T. Baggett, JD

Dawn T. Baggett

USA
(334)380-0305 • dawn@dawnbaggett.com