InBody Intake Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
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Yes
No
Date of Birth
*
-
Month
-
Day
Year
Wellness Focus
Primary Area(s) of Focus - select all that apply
*
Longevity / Healthy Aging
Increase Muscle Mass
Weight Loss / Body Fat Reduction
Improve Cardiovascular Health
Secondary Goals
*
Goals
What Are Your Top 1-3 Wellness Goals
*
Medical Conditions
Check All That Apply
*
Hypertension
Hyperlipidemia
Prediabetes
Type 1 Diabetes
Type 2 Diabetes
Cardiovascular Disease
Thyroid Disorder
Sleep Apnea
Obesity
Chronic Pain / Arthritis
Anxiety / Depression
Gastrointestinal Disorder
None Reported
Other
Pertinent Labs (If Known)
A1c (%):
Date of A1C Test:
-
Month
-
Day
Year
Date
Fasting Glucose (mg/dL):
Total Cholesterol (mg/dL):
LDL:
HDL:
TG:
Blood Pressure (average):
Other Labs:
Check Here If Labs Are Unknown
Allergies
Do you have allergies?
*
Yes
No
If yes, list below:
Current Medications
Medication Profile Reviewed in Pioneer
No Current Medications
Additional Notes (if needed):
Current Supplements
Are You Currently Taking Any Supplements?
Yes
No
If Yes, List Supplements Below
Exercise & Activity
Current Activity Level:
Sedentary
Light (1-2 Days/Week)
Moderate (3-4 Days/Week)
High (5+ Days/Week)
Type of Exercise (Check All That Apply):
Resistance Training
Cardio
HIIT
Sports
Mobility/Yoga
Average Session Duration:
Less Than 30 Minutes
30 - 60 Minutes
More Than 60 Minutes
Sleep
Average Sleep Per Night:
Less Than 6 Hours
6-7 Hours
7-8 Hours
More Than 8 Hours
Sleep Quality:
Poor
Fair
Good
Excellent
I Have:
Difficulty Falling Asleep
Difficulty Staying Asleep
Snoring/Sleep Apnea
No Concerns About My Sleep
Nutrition
Current Dietary Pattern:
Standard America
High Protein
Low Carb / Keto
Mediterranean
Plant-Based
Other
Nutrition Habits (Check all That Apply):
Regular Meals
Frequent Snacking
Late-Night Eating
Sugary Beverages
Adequate Hydration
Readiness to Change
How Motivated Are You To Make Lifestyle Changes? (Scale 1-10):
1
2
3
4
5
6
7
8
9
10
What Has Made It Difficult To Reach Your Goals In The Past?
Acknowledgment
Sign Name Below:
*
Type full name to sign.
Patient understands wellness coaching and InBody assessments are non-diagnostic and not a substitute for medical care.
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