Lifestyle Survey
Lisa Rubenstein - Rubenstein Health, LLC
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Today's date
Email
*
example@example.com
Address
Street Address
City
State / Province
Postal / Zip Code
Date of Birth
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of contact:
*
Call
Email
Text
Sleep
What time do you usually wake up?
What time do you usually go to bed?
Do you wake in the middle of the night often?
Hydration
How much water do you drink in a day?
*
How much coffee do you consume in a day?
How much alcohol do you drink in a week?
Movement
How many times a week do you exercise?
What kind of exercise do you participate in?
Are there things you would like to do, that you currently are not physically able to?
Stress
What do you do for work?
Do you work in an office or from home?
How would you rate your stress level?
Eating Habits
What time do you eat your first meal?
*
What time do you eat your last meal?
Do you snack? If yes, on what?
How often do you eat out in a week?
Where do you eat out at?
Weight
Current weight:
*
Goal weight:
*
What is your height?
*
Have you tried to lose weight before?
If yes, what have you found most difficult about losing weight in the past?
Submit
Thank you! I will be in touch with you shortly. You can also email me at lrubenstein57@gmail.com or text me at 9145229954.
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