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Lean Wellness Start-Up

Individual information will not be shared. This information is used to provide content to individual program design and development. Thank You, Randy Bauer

Q.1

How Satisfied are you in the following areas of Wellness (low=Trace, high=Excellent).

	Trace	Poor	Fair	Good	Excellent
Fitness
Stress
Body Weight
Pain
Nutrition
Health

Fitness

Trace Poor Fair Good Excellent

Stress

Trace Poor Fair Good Excellent

Body Weight

Trace Poor Fair Good Excellent

Pain

Trace Poor Fair Good Excellent

Nutrition

Trace Poor Fair Good Excellent

Health

Trace Poor Fair Good Excellent

Q.2

What area of your Wellness is in need of Change?

This may be an area that is your Top Priority

Fitness
Stress
Body Weight
Health
Nutrition
Injury/Pain

Please help us understand why you selected this answer

Q.3

Only required if you wish to discuss results and participate in Wellness Program.

(e.g. john@example.com)

Q.4

Only required if you wish to discuss results and participate in Wellness Program.

Title

First Name

Last Name

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