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Disclaimer
Please recognize the fact that it is your responsibility to work directly with your physician before, during and after seeking health consultation. As such, any information provided is not to be followed without the prior approval of your physician. If you choose to use this information without the prior consent of your physician, you are agreeing to accept full responsibility for your decision.
Disclaimer Signature
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Profile & Demographics
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Sex
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Male
Female
Non-binary
Transgender
If Other, Please Describe
Date of Birth
-
Year
-
Month
Day
Date
T-Shirt Size
S
M
L
XL
XXL
XXXL
What is your primary profession
Athlete
Non-Athlete
Please describe: teacher, lawyer, physician, astronaut, etc.?
If forced to only choose from these options, which describes you best?
Please Select
Prefer the big picture - just give me the jist of it, I’ll take it from there
Keep it simple - too much information is overwhelming and suffocating
High precision - it’s calming to know exactly what, when, and how to do
Limit options - I do much better with strict and specific rules
If forced between these two, what would you pick?
Please Select
Let me focus on one thing, get it done, then bring in the next
Give it all to me at once so I can see the whole picture and get going on everything right away
How did you hear about us?
Barbell Shrugged
Heard Dan or Andy on a podcast
Referred from a friend
Social media
Professional conference, clinic, or seminar
If Other, briefly describe
Which podcast did you hear Dan or Andy on?
Do you have any sponsors relevant to our work (e.g., supplements, sleep, meal prep, recovery, etc.)
Medical & Health
Do you understand that we are NOT medical professionals or physicians and thus do not diagnose nor treat any medical conditions nor diseases?
Please Select
Yes
No
Do you have any diagnosed medical conditions?
Please Select
Yes
No
If yes, please describe:
Do you take any medications for health reasons, prescribed or not (this does not include performance supplements - we’ll get to those later)?
Please Select
Yes
No
Medication Details
Rows
Name of medication
Brand/company
How long have you been taking it for?
Why do you take it?
How much do you take?
How often do you take it?
Any additional comments?
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
If applicable, please describe any current or former use of anabolic steroids, performance enhancing drugs, or hormone replacement therapies.
Do you have any previous major surgeries we should be aware of?
Please Select
Yes
No
Surgery Details
Rows
What was the surgery?
Why did you need the surgery?
Does the surgery limit you in any way now?
Surgery 1
Surgery 2
Surgery 3
Surgery 4
Surgery 5
Do you have any current injuries that are more than minor (i.e, things that take more than a few days to heal)?
Please Select
Yes
No
Injury Details
Rows
What is the injury (e.g., left knee sprain)?
When did the injury occur (exact date not necessary)?
What therapies/interventions have you been using to treat the injury?
Injury 1
Injury 2
Injury 3
Injury 4
Injury 5
Do you have any other current movement limitations?
Please Select
Yes
No
If yes, please describe
Any other medical concerns (physical, mental, or otherwise), currently or in the past, that we should be aware of?
Please Select
Yes
No
If yes, please describe
How often do you get sick?
Please Select
More often than most people
Probably the same as most people
Very rare/almost never
I'm not really sure
Have you given birth?
Are you...
Please Select
Pre-menopause
Going through menopause now
Post-menopause
Do you have a normal menstrual cycle from a timing perspective?
Please Select
Yes
No
If not, please describe
Do you have a normal menstrual cycle from a symptom perspective?
Please Select
Yes
No
If not, please describe
Do you have a normal menstrual cycle from a bloodflow perspective?
Please Select
Yes
No
If not, please describe
Are you currently on any form of birth control?
Please Select
Yes
No
If yes, please describe
Do you have/have you ever been told you have PCOS (polycystic ovarian syndrome)
Please Select
Yes
No
Part 2: Goals
Which best describes the primary reason for wanting to work with us?
Feel great, just want to make sure I’m optimizing
I have a very specific reason such as poor performance, inability to hit a certain goal, suspect you’ve got something wrong, excessive fatigue, etc.
If Other, please specify
Please describe your reason - and be specific
In an ideal world, what would be the top 1-5 accomplishments you want to achieve while working with us? (please describe)
Of these, which would you consider to be your #1 priority? Please list that goal as specific as possible. Example: “I want to lose 25 pounds by July 4th”.
What do you feel like is holding you back from achieving that primary goal?
Do you have a particular event or competition you are specifically targeting next? (e.g., World Title fight, wedding, start of NFL season, etc.).
Please Select
Yes
No
What is the event?
When is your event date?
-
Year
-
Month
Day
Date
What are your short-term goals? (3-5 months)
What are your long-term goals? (>6 months)
Please rank the following in order of importance, with 1 being the most important and 8 being the least important
Part 3: How You Feel
Overall, how do you feel?
Please Select
As terrible as I can imagine
Crummy, but it could be worse
Meh
Pretty good, but want to feel better
Freaking incredible
How long have you been feeling this way?
Please Select
Last 1-3 months
Last 3-6 months
Last 6-12 months
Several years, but not before that
My whole life, basically
Why do you think you feel this way (i.e. I’m in physical pain/my body hurts, I don’t have any energy/sleepy, I’m depressed, my job/life are too hectic, etc.)?
What are your energy levels on a daily basis?
Please Select
1
2
3
4
5
6
7
8
9
10
10 is high energy || 1 is low energy
Do you have any pain or stiffness in your joints upon waking?
Please Select
Yes
No
Pain/Stiffness Details
Rows
Location (e.g., neck, low back, etc.)
How often (e.g., every morning, 1x/week, etc.)
How bad (e.g., very stiff, little pain, etc.)
Pain/Stiffness 1
Pain/Stiffness 2
Pain/Stiffness 3
Pain/Stiffness 4
Pain/Stiffness 5
How stressed do you feel on a daily basis?
Please Select
1
2
3
4
5
6
7
8
9
10
Has this changed at all recently?
Please Select
Yes
No
If yes, please describe
Has your overall stress level changed recently?
Please Select
Yes
No
If yes, how much has it changed and why?
How much does each of the following contribute to your total stress load (0 being nothing at all, 10 being cripplingly amounts)?
Rows
Number
Psychological (e.g., past trauma, anxiety, depression, etc.)
Emotional (e.g., issues with family, relationships, or coaches/teammates, etc.)
Physical (e.g., second job or required extra training, etc.)
Financial or Business (e.g., income, lawsuits, contract issues, etc.)
Other
Specifically describe the single largest contributor to stress in your life.
Describe your daily brain power (focus, attention, memory, etc)
Please Select
0
1
2
3
4
5
6
7
8
9
10
Has this changed at all recently?
Please Select
Yes
No
If Yes, please describe
How ambitious and driven are you? (0 being not at all, 10 being extremely)
Please Select
0
1
2
3
4
5
6
7
8
9
10
Has this changed at all recently?
Please Select
Yes
No
If Yes, please describe
How do you classify your sex drive, relative to your peers?
Please Select
Never really thought about it/I don’t know
Definitely way higher
Probably higher, but not sure
Same as everyone else
Probably lower, but not sure
Definitely way lower
Basically zero
How do you classify your sex drive, relative to yourself?
It’s too high
It’s fine/where I want it - or close enough anyways
It’s too low
It doesn’t exist
No clue, never thought about it
If None of these, please elaborate
Men, do you have trouble achieving or maintaining an erection?
Women, do you have difficulties with vaginal dryness or pain during intercourse?
How well do you feel your digestion is?
Please Select
1
2
3
4
5
6
7
8
9
10
Do you suffer from bloating, distension, discomfort, acid reflux, or any other GI symptoms on a regular basis?
Please Select
Yes
No
If yes, please describe
How regular are your bowel movements?
Please Select
Usually 3+ times per day
Usually 2-3 per day
Usually 1-2 per day
Usually 1x per day
Not daily
Do your bowel movements pass easily?
Please Select
Yes
No
What type of consistency is the stool during your typical bowel movements?
Please Select
Seperate hard lumps, like nuts (hard to pass)
Sausage-shaped but lumpy
Like a sausage but with cracks on it's surface
Like a sausage or snake, Smooth and soft
Soft blobs with clear-cut edges (passed easily)
Fluffy pieces with ragged edges, a mushy stool
Watery, no solid pieces. Entirely Liquid
Part 4: Lifestyle and Home Environment
What phase best describes you right now?
Please Select
In-season
Post-season
Off-season
Pre-season
During this phase of the year (e.g., your selection from the prior question), when you’re not training, what does the rest of your day look like?
Virtually nothing, just relaxing, recovering, sleeping, playing with kids, and/or video games, etc.
Moderately active, some relaxing mixed with a few business and/or sport-related activities/meetings and things like that, etc.
Pretty busy with family responsibilities, business ventures, and/or sport-related work (e.g., film, sport psychology, meeting with coaches, etc.).
Extremely busy, my entire day is planned out to the 15 min window.
Other (please describe):
What are your two largest priorities in life right now?
How do you generally divide your energy/time across the following 4 major categories? Use a total of 10 points (NOT 10 per category).
Rows
Points
Business/work
Relationships/kids/friends/family
Recovery (personal time, massage, meditation, etc.)
Physical training/exercise/working out
How consistent is your daily schedule?
Please Select
Not at all: Every day is completely different, I figure it out as I go
Pretty consistent: I wake up and go to sleep and workout at roughly the same time (+/-) an hour most days
DIALED: I wake up, eat, train, and do pretty much everything at the exact same time every day. I rarely deviate from it.
What does your daily routine look like?
Rows
Activity
Details
4am
5am
6am
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
12pm
1am
2am
3am
How often are you traveling (>2 hr drive or any flight) right now?
Please Select
Rarely
A few times a month
Weekly
Are you the primary caregiver for children or any adults (e.g., individuals with disabilities, elderly relatives, etc.)?
Please Select
Yes
No
Where do you get most of your drinking water from?
Tap, no filtration system
Tap, but we've got a filtration or reverse osmosis system built into our sink
Tap, but we use a filter (Brita) and keep it in the fridge
Bottles from the store like Aquafina, smart water, etc.
Large refillable plastic jugs that we fill in the store
Other, Please Specify
What type of food containers or "Tupperware" do you generally use?
Never use anything like this
Plastic
Glass
Some glass, some plastic
Other, Please Specify
Do you use "free & clear" products for your personal health, hygiene, laundry, and house cleaning?
Yes, almost exclusive use "F&C" or other things like it
Kinda. Some things we do, others we don't
What the hell is "free & clear"?
No, I brush my teeth with lead pencils and shower in bleach
Other, Please Specify
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