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MEMBERS

We Meet You Where You Are

Discover your now. Define your next. Design your path.

You’re here because you’re ready for more — more energy, confidence, and alignment with the person you want to become. Transformation starts with awareness. When you know where you are, we can help you define where you want to go and create a plan that fits your life — simple, sustainable, and uniquely yours.

Take a minute to share your current reality, goals and what’s been holding you back. We’ll meet you there and help you take the next step toward your next level of health and life.

First Name *

Last Name *

Email *

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Who referred you to this form? *

Mishael Barton
Traci Cain
Raye Gall
Kristin Gillis
Wendy Hushon
Anna Lavenhar
Christine Lindner
Dr. Scott Massey
Rick McAllister
Kelsey Pope
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If you selected other, please share how you found us!

What would you like to achieve or improve with your overall health or wellness? *

Why are the things you listed in the previous question important to you? What do you think will be different in your life when you make changes in these areas?

Tell us about a time in your life when you felt your best. What has changed since then?

On a scale of 1-10, how would you rate your overall contentment?

On a scale of 1-10, how much do you worry?

What in life causes you the most stress?

On average, how many days per week do you reflect on your day by journaling or sharing with others?

On average, how many days each week do you engage in prayer, reading your Bible or meditating?

How many hours of sleep do you get on a typical night?

9+
7-8
5-6
<5
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How would you describe the quality of your sleep?

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In the past seven days, how would you rate your fatigue on average?

None
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Briefly describe your average day of eating. How many times do you eat? Are you planning ahead or grabbing whatever is available? Please include both meals and snacks.

On average, about how many ounces of water do you drink a day?

On average, how many minutes each week do you engage in moderate to strenuous exercise? What type?

To what extent are you able to carry out your every day physical activities such as walking, climbing stairs, carrying groceries, etc.

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A little
Moderately
Mostly
Completely
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Are you taking any of the following medications, or any medications for: *

Diabetes

High Blood Pressure

Thyroid

Coumadin (Warfarin)

Lithium

None

Other

Do you have any food allergies or sensitivities? *

No

Peanuts

Dairy

Gluten

Soy

Egg

Other

Are you currently participating in a medically supported weight loss program? Or is this something you have considered?

In general, would you say your health is...

Poor
Fair
Good
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In general, would you say your quality of life is...

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In general, how would you rate your physical health?

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In general, how would you rate your mental health, including your mood and ability to think?

Poor
Fair
Good
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TExcellentype an Option
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In general, how would you rate your satisfaction with your social activities and relationships?

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On a scale of 1-10, how committed are you to getting to your health and wellness goals?

At UpLevel Wellness, we believe true health is alignment — when your values, energy, actions,

and purpose are working together.

Our mission is to guide you on a journey toward holistic well-being, empowering you to live with intention, clarity, and vitality.

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