RAPID Intake - Section 1

Approximate Time: 20 mins

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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*
Profile & Demographics
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Sex*

MaleFemaleNon-binaryTransgenderIf Other, Please Describe
Date of Birth

YearMonthDay
Date
T-Shirt Size

SMLXLXXLXXXL
What is your primary profession

AthleteNon-Athlete
Please describe: teacher, lawyer, physician, astronaut, etc.?
If forced to only choose from these options, which describes you best?
If forced between these two, what would you pick?
How did you hear about us?

Barbell ShruggedHeard Dan or Andy on a podcastReferred from a friendSocial mediaProfessional conference, clinic, or seminarIf 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?
Do you have any diagnosed medical conditions?
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)?

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?

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)?

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?
If yes, please describe
Any other medical concerns (physical, mental, or otherwise), currently or in the past, that we should be aware of?
If yes, please describe
How often do you get sick?
Have you given birth?
Are you...
Do you have a normal menstrual cycle from a timing perspective?
If not, please describe
Do you have a normal menstrual cycle from a symptom perspective?
If not, please describe
Do you have a normal menstrual cycle from a bloodflow perspective?
If not, please describe
Are you currently on any form of birth control?
If yes, please describe
Do you have/have you ever been told you have PCOS (polycystic ovarian syndrome)
Part 2: Goals
Which best describes the primary reason for wanting to work with us?

Feel great, just want to make sure I’m optimizingI 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.).
What is the event?
When is your event date?

YearMonthDay
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?
How long have you been feeling this way?
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?
10 is high energy || 1 is low energy
Do you have any pain or stiffness in your joints upon waking?

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?
Has this changed at all recently?
If yes, please describe
Has your overall stress level changed recently?
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)
Has this changed at all recently?
If Yes, please describe
How ambitious and driven are you? (0 being not at all, 10 being extremely)
Has this changed at all recently?
If Yes, please describe
How do you classify your sex drive, relative to your peers?
How do you classify your sex drive, relative to yourself?

It’s too highIt’s fine/where I want it - or close enough anywaysIt’s too lowIt doesn’t existNo clue, never thought about itIf 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?
Do you suffer from bloating, distension, discomfort, acid reflux, or any other GI symptoms on a regular basis?
If yes, please describe
How regular are your bowel movements?
Do your bowel movements pass easily?
What type of consistency is the stool during your typical bowel movements?
Part 4: Lifestyle and Home Environment
What phase best describes you right now?
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?

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?
Are you the primary caregiver for children or any adults (e.g., individuals with disabilities, elderly relatives, etc.)?
Where do you get most of your drinking water from?

Tap, no filtration systemTap, but we've got a filtration or reverse osmosis system built into our sinkTap, but we use a filter (Brita) and keep it in the fridgeBottles from the store like Aquafina, smart water, etc.Large refillable plastic jugs that we fill in the storeOther, Please Specify
What type of food containers or "Tupperware" do you generally use?

Never use anything like thisPlasticGlassSome glass, some plasticOther, 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 itKinda. Some things we do, others we don'tWhat the hell is "free & clear"?No, I brush my teeth with lead pencils and shower in bleachOther, Please Specify
By signing below, I certify all information is true and correct to the best of my knowledge.*
Should be Empty:

Approximate Time: 20 mins

Disclaimer

Profile & Demographics

Medical & Health

Part 2: Goals

Part 3: How You Feel

Part 4: Lifestyle and Home Environment