While the How is important, YOUR WHY is even more so. Experts say it can account for 95% of your success. Review your 5 Pillars of Health. Where are you currently? Where would you like to be? Rate yourself on a scale of 1 to 10, ten being your ideal. Be honest with yourself! Today1 Year3 Years5 Years Your Body___________________________ Your Mind___________________________ Your Family___________________________ Your Society___________________________ Your Finances___________________________ “Success is the progressive realization of a worthy ideal.” … Earl Nightingale The Nikken philosophy of total wellness rests on the 5 Pillars of Health and is achieved by creating balance in relation to the 5 Pillars. Now it’s time to evaluate your life in relation to the 5 Pillars. Client Information PURPOSE Name: _____________________________________________ Address: ___________________________________________ ___________________________________________________ City: _______________________________________________ State/Province: _____________Zip/Postal Code: ___________ Day Phone: ______________Evening Phone: ______________ Email Address: _______________________________________ 1 Wellness Profile printable PDF version available in New Partner Tool Box – Business Forms Folder
WELLNESS PROFILE Health Concerns Do you have a Pacemaker or other implanted electronic device? Yes____ No____ Are you pregnant? Yes____ No____ Do you have any specific concerns about your back or general health? Yes____ No____ Explain_______________________________________ Lifestyle Information Sleep Are you able to fall asleep quickly? Yes____ No____ How many hours do you sleep each night?______ In what position do you sleep? Back____ Side ____ Stomach_____ How long have you had your present mattress? Years__ Size: Twin___ Full___ Queen___ King__ Cal King____ Firmness: Hard____ Firm____ Soft_____ Do you like this degree of firmness? Yes____ No____ If No, you’d prefer? Hard__ Firm___ Soft_____ Do you toss and turn during the night? Yes_____ No _____ Do you wake feeling refreshed and ready to go? Yes_____ No______ During the day, how do you feel? Alert and energized ______ Fatigued______ Do you have trouble falling asleep because of too much light? Yes______ No_____ Do your eyes look tired if you haven’t slept well? Yes______ No______ Do you tend to feel too hot or too cold during sleep? Yes_____ No ______ Nutrition Do you take any nutritional supplements regularly? Check those that apply. Multi Vitamin/Mineral _______ Joint Support _______ Digestion Support______ Men’s/Women’s specific formula_____ Fiber_______ Sleep Aid ______ Antioxidant______ Memory________ Liver Detoxify_______ Fat Burner_______ Do you eat nutrition bars? Yes_____ No_____ Water What type of water do you drink? Tap____ Bottled_____ Filtered_____ Other_______ Do you use a shower filter? Yes_____ No_____ Do you live in an area that has “hard” water? Yes_____ No_____ Comfort, Support and Massage Have you ever had a massage? Yes_____ No_____ Do you have tension in your back, neck or shoulders? Yes_____ No_____ Do you have foot discomfort? Yes_____ No_____ Do you have any joint discomfort? Yes_____ No_____ If Yes, where?______________ Do you spend a great deal of time sitting? (car, office etc) Yes_____ No_____ Skin Care Are you concerned about the appearance of your skin? Yes_____ No_____ 2 Complete the Evaluation! ___ Yes, book me for a Product Demo___ Yes, book me for the Business Plan Overview
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