Wellness Self-Assessment - GenesisX Life™

If you’re experiencing health challenges and want a clear place to start, this Wellness Self-Assessment is for you. By answering a few simple questions about your lifestyle, environment, and daily habits, you’ll gain valuable insight into areas that may be affecting your well-being — while also giving us a better understanding of how to support you on your GenesisX journey.

Confidentiality Note: Everything you share here is private and will only be used to help guide your GenesisX experience.

First Name *

Email Address *

Phone Number

Phase 1: Cleanse – Body & Lifestyle

Sleep & RestI usually sleep 7–9 hours per night.I have trouble falling asleep.I wake up often during the night.I wake up feeling rested.I nap during the day.

Physical ActivityI exercise regularly (3+ times per week).I go for walks daily.I sit for long periods of time.I stretch or move my body daily.I spend time outdoors daily.I practice yoga, tai chi, or another mindful movement.

Medical BackgroundI currently take prescription medications.I use over-the-counter medications often.I take supplements or natural remedies.I live with a chronic health condition.I’ve had major surgeries.I’ve received vaccines in the past 5 years.I regularly see a healthcare professional for checkups.

Phase 2: Connect – Mind & Spirit

Energy & EmotionsI wake up with good energyI experience frequent fatigue or brain fogI experience headaches oftenI have regular emotional ups and downs

Phase 3: Create – Environment & Relationships

PetsI live with cats.I live with dogs.I live with other pets (please specify).My pets are regularly checked by a vet or dewormed.

What are your top 3 health concerns right now?

What are your top 3 health goals?

Is there anything else you’d like to share about your lifestyle, environment, or history?