Muscle Nutrition Screening

muscle fix mobile: Health Coach

Thank you for taking our health survey so we can tailor a program to meet your goals!
Name

First NameLast Name
E-mail
example@example.com
Best number to reach you on
Format: (000) 000-0000.
Date

MonthDayYear
Date
Age
Musclefixmobile.com
How did you hear about me or our programs?
What would you like to accomplish most with your health right now (lose weight, sleep better, less stress, come off medications, more energy, etc)?
Please describe WHY you are interested in getting healthy. (What is your main motivation? Relationships, activities, how you feel, etc)
Do you have any pain or tightness in your bod
Would you like to reserve a cupping session with dr nick dpt
Medical

We can discuss some medical considerations when we chat.
Sleep
How many hours of sleep do you typically get?
What time do you typically wake up?
How is your quality of sleep and do you wake up feeling rested?
Hydration
How much water do you drink each day?
CoffeeSodaTeaAlcoholJuice (Apple, Orange, Fruit, etc)
Motion
How would you rate your daily energy level on a scale of 1 (lowest) to 10 (highest)?
Do you currently exercise? If so, how many times a week?
What physical / exercise activities do you participate in?
How would you describe your daily activity level?
Stress
How would you rate your stress level on a scale of 1-10?
What do you do for work?
Are there any other stressors in your life?
Eating Habits
How many meals per day do you eat?
Do you snack in between meals? If so, what snacks?
How many days a week do you eat out or grab food on the go? (coffee runs, fast food, sit down restaurants, take out, vending machines, etc)
Weight
Current Weight: (if you want to share)
In a perfect world, if you could not fail, how many pounds would you want to lose?
Height:
What has been the most difficult thing about losing weight in the past?
Is there anyone in your life who would like to get healthy with you?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
On a scale of 1 to 10, how ready are you to make changes to improve your health?

1

2

3

4

5

6

7

8

9

10

1 is Just thinking about it, 10 is Ready to do this
If you would like to schedule a follow-up call to further discuss your health goals and what programs might work best for you, please feel free to use this link to schedule a time.
Should be Empty:

muscle fix mobile: Health Coach

Medical

Sleep

Hydration

Motion

Stress

Eating Habits

Weight