SayPro Health and Wellness Questionnaire

Objective: To gather information about participants’ current health status, habits, and goals, which will help personalize their experience at the SayPro Health and Wellness Camp. This will also allow the facilitators to tailor sessions to better meet individual needs.

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Participant Information

1. Full Name:
2. Age:
3. Gender:
   • Male
   • Female
   • Non-Binary
   • Prefer not to answer
   • Other: _______________________
4. Email Address:

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Health and Lifestyle Habits

5. How would you rate your overall health currently?
   • Excellent
   • Good
   • Fair
   • Poor
6. Do you have any chronic health conditions (e.g., diabetes, high blood pressure, asthma)?
   • Yes (please specify): _____________________________________________
   • No
7. Do you currently follow any specific diet (e.g., vegetarian, vegan, keto, gluten-free)?
   • Yes (please specify): _____________________________________________
   • No
8. Do you have any food allergies or intolerances?
   • Yes (please specify): _____________________________________________
   • No
9. How many servings of fruits and vegetables do you typically eat per day?
   • Less than 1 serving
   • 1–2 servings
   • 3–4 servings
   • 5 or more servings
10. How many meals do you typically eat each day?
    • 1 meal
    • 2 meals
    • 3 meals
    • 4 or more meals
11. Do you snack between meals?
    • Yes
    • No
    • If yes, what do you usually snack on? ___________________________
12. How many times per week do you engage in physical activity (e.g., walking, running, yoga, gym)?
    • 0 times
    • 1–2 times
    • 3–4 times
    • 5 or more times
13. What type of physical activity do you currently enjoy most? (e.g., walking, running, yoga, swimming, strength training)
14. Do you have any injuries or conditions that affect your ability to exercise?
    • Yes (please specify): _____________________________________________
    • No
15. How would you rate your current level of physical fitness?
    • Very fit
    • Moderately fit
    • Slightly fit
    • Not fit at all
16. Do you regularly practice mindfulness or relaxation techniques (e.g., meditation, deep breathing, yoga)?
    • Yes, daily
    • Yes, occasionally
    • No
17. How would you rate your stress levels on a typical day?
    • Very low stress
    • Low stress
    • Moderate stress
    • High stress
    • Very high stress
18. How well do you sleep on average per night?
    • Less than 4 hours
    • 4–5 hours
    • 6–7 hours
    • 8 hours or more

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Health Goals and Expectations

19. What are your primary health and wellness goals for attending this camp? (Select all that apply)
    • Improve nutrition and healthy eating habits
    • Build a consistent fitness routine
    • Manage or reduce stress
    • Increase mindfulness and mental clarity
    • Lose weight
    • Improve sleep quality
    • Increase energy and vitality
    • Improve overall physical health
    • Other (please specify): _______________________
20. What challenges have you faced in achieving these goals in the past?
    • Lack of time
    • Lack of motivation
    • Limited knowledge or guidance
    • Poor habits or routines
    • Health conditions/injuries
    • Other (please specify): _______________________
21. What areas of your health would you like to focus on the most during this camp?
    • Nutrition and meal planning
    • Fitness and exercise routines
    • Stress management and mindfulness
    • Sleep improvement
    • Emotional well-being
    • Other (please specify): _______________________
22. What do you hope to achieve by the end of the camp? (e.g., consistency in healthy habits, feeling more energized, losing weight)

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Additional Information

23. Do you have any specific concerns or questions that you would like to address during the camp?
24. Is there any additional information you feel is important for the facilitators to know about your health or wellness?

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Consent and Agreement

25. Medical Waiver:
    I acknowledge that participation in physical activities may involve a risk of injury. I hereby release the SayPro Health and Wellness Camp organizers, facilitators, and staff from any liability in the case of an accident, injury, or health-related incident during the camp.
    • I agree to the terms and conditions.
26. Photo/Video Release:
    I consent to the use of photos, videos, and testimonials captured during the camp for promotional purposes.
    • I agree
    • I do not agree

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Thank you for completing this questionnaire! Your responses will help us create a personalized experience tailored to your needs and goals. We look forward to working with you at the SayPro Health and Wellness Camp!