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First Responder -  Intake Questionairre

First Responder -  Intake Questionairre

Fill out this form prior to your Assessment Discovery Call
51Questions
  • 1
    Use the name that is associated with your billing. Please additionally include preferred name.
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  • 2
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  • 3
    Month/Day/Year
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  • 6
    including gym time, self care routines, walks etc.
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  • 7
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  • 8
    If yes, please describe your experience and list and negative or positive aspects.
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  • 9
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  • 10
    If its different for each element please list for each.
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  • 14
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  • 15
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  • 16
    what is the frequency and duration typically of the nap?
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  • 17
    Meaning do you feel tired getting home from work, or just after dinner and then right before bed you seemingly get a burst of energy
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  • 18
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  • 19
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  • 20
    If yes, please describe in as much detail as possible.
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  • 21
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  • 22
    if yes please list them with the reasons why.
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  • 23
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  • 25
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  • 26
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  • 27
    1 bottle of water is 17ounces
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  • 28
    Be as specific as possilbe for example. Your drink 6 beers per week include the brand. If you can also be descriptive in how these drinks are distributed. If you have 1 beer per day for 6 days. Or is that 6 in one night.
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  • 29
    If yes, please list below
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  • 30
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  • 31
    if unsure or not comfortable finding out what that number is for personal reasons please ignore this question)
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  • 32
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  • 33
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  • 34
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  • 35
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  • 36
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  • 37
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  • 38
    List in order of importance
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  • 39
    Ex). Sprained ankle 5 years ago, Surgeries, IBS, Diabetes etc.
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  • 40
    (including laxatives, appetite suppressants, tranquilizers, pain relievers, antacids, sleeping aids, birth control, cortisone, Marijuana, CBD etc)
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  • 41
    childbirth, minor surgeries, emergencies, even old injuries could be of relevance so include as much detail as you can.
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  • 42
    (massage, accupuncture, physical therapy, rehab etc)
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  • 43
    including food, environment, chemicals, dust, mold, etc)
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  • 44
    Even if not a “candy” kid, did you drink a lot of juice, cereal etc.
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  • 45
    If you haven’t started your career as a first responder you can answer in regards to what lifestyle change would have the biggest impact on your upcoming testing.
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  • 46
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  • 47
    If still training for a test, what is your biggest concern or limiting factor leading into the test that you would like to improve on?
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  • 48
    Do you find advice and criticism motivating or does it cause you to dwell, overthink or have negative emotions associated with it? Or does that blunt style light a fire inside?
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  • 49
    If you have a detailed document available that you could email instead of having to rewrite it all feel free to send that to this email instead: themodeltrainer22@gmail.com
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  • 51
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