Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
City, State
What is your age and gender?
What are your hobbies?
List physical limitations due to injury and/or medical conditions?
What is your occupation?
How many hours a day are you at work?
Do you have any dependents? Be specific:
Diet:
How would you describe your current diet?
Do you consume a balanced variety of fruits, vegetables, lean proteins, and whole grains?
Typically, how many meals do you eat per day?
Are you currently taking a multivitamin or dietary supplements? If so, list them:
How would you describe your diet?
Regular
Lacto-ovo
Vegetarian
Vegan
Other
Typically, how many meals do you eat outside of the home per week?
What is your favorite cuisine?
American
Mexican
Chinese
Japanese
Indian
Other
Physical Activity:
How often do you engage in physical activity or exercise each week, and what types of activities do you enjoy?
How would you describe your typical daily routine? Are there any sedentary activities or prolonged periods of sitting?
Water:
How much water do you drink per day?
How would you describe the color of your urine?
Pale
Bright Yellow
Other
Natural Light:
How often do you get outside in the sunlight?
How long do you stay out at one time?
Lifestyle:
Do you smoke tobacco products or have you in the past? If so, how frequently?
How would you rate your stress levels on a scale from 1 to 10, with 10 being the highest? What are the main sources of stress in your life?
Do you regularly consume alcohol or use recreational drugs? If so, how frequently and in what quantities?
Have you experienced any recent significant life changes or traumatic events that may be affecting your mental or emotional well-being?
Do you have a support system in place for managing stress and coping with life's challenges? Describe:
Do you have supportive relationships? List them:
How would you rate your overall satisfaction with your current lifestyle and health habits? Are there any specific areas you would like to improve upon?
Fresh Air:
How many hours do you spend indoors per day?
How many hours do you spend outdoors per week?
Sleep and Rest:
On average, how many hours of sleep do you get per night?
Do you experience any difficulties falling or staying asleep?
How many days per week do you work?
How often do you "get away"? Explain:
Spirituality:
Do you harbor any resentments from your past?
How often do you do something for someone else?
Do you regularly attend church or other religious services?
Medical Conditions and Physical Limitations:
Do you have any existing medical conditions or chronic illnesses?
If so, how do they impact your daily life and physical activity levels?
Are you currently taking any prescription medications?
Do you have any injuries that have not completely healed? Describe:
Do you have pain? If yes, please explain.
Submit
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