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Readiness for Change Questionnaire

Lasting wellness begins with readiness -- the willingness to take small, consistent steps toward change. ​This brief questionnaire helps us understand your motivation, mindset, and confidence as you begin (or continue) your lifestyle transformation journey.

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Your answers are confidential and will help us create a realistic, personalized plan that meets you where you are.

Results will be sent to your email.

Section 1: Motivation & Mindset

How would you rate your current motivation to improve your health
How confident do you feel about your ability to follow a wellness plan?
How ready do you feel to make changes to your daily habits right now?

Section 2: Support & Environment

Do you feel supported by family or friends in making lifestyle changes?
Do you have a structured environment (home, work, schedule) that allows for self-care?

Section 3: Stress, Energy & Emotional Readiness

How would you describe your overall stress level right now?
Do you feel emotionally ready to take time for yourself and your health?
Do you feel you have enough energy to begin making small changes?

Section 4: Commitment & Accountability

How much time can you realistically dedicate each week to your health goals?
Do you prefer accountability through:
What motivates you most?

Section 5: Reflection

Consent & Acknowledgement

By submitting this form, I acknowledge that the information provided is truthful to the best of my knowledge. I understand that this questionnaire is for wellness and educational purposes only and does not establish a medical provider–patient relationship. I further understand that the results will be reviewed by Dr. Sandra McKenzie for the purpose of offering general wellness guidance or discussing next steps, and that any personalized recommendations will require a formal consultation.

This questionnaire is a screening tool, not a diagnosis.

Results help guide awareness and discussion.

Personalized recommendations require a clinical consultation.

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