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Free Health Assessment Intake Questionnaire
Member Initial Assessment-CONFIDENTIAL
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Basic Information Demographics
Member
Other:
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Today’s Date
MM
/
DD
/
YYYY
First Name
Your answer
Last Name
Your answer
Phone Number
Personal
Email
Your answer
Gender
Female
Male
Prefer not to say
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Age
Your answer
Birthday (Optional)
MM
/
DD
/
YYYY
Address (Optional)
Your answer
City (Optional)
Your answer
State (Optional)
Your answer
Zip Code (Optional)
Your answer
What are your wellness goals?
Short term-12-week challenges (starting February 1 2026)
Long term 3 months to 6 months
To get stronger
To eat healthier
Join a supportive community
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Current Weight (lbs)
Your answer
Goal Weight (lbs)
Your answer
Height
Your answer
How much weight do you want to lose or gain? (lbs)
Your answer
What other wellness programs or products have you tried?
Your answer
What results have you experienced?
Your answer
Eating Habits
Fuel Eating.
Joy Eating
Fog Eating
Storm or Stress Eating
Other:
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Do you eat three meals a day?
Yes
No
Maybe
Option 4
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If no, which meals do you skip?
Breakfast
First meal mid-morning
Lunch
Snack
Dinner
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What did you eat yesterday?
Breakfast
Snacks
Lunch
Dinner
Do you snack?
Yes
No
Maybe
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If yes, what time of day do you snack?
Your answer
What do you snack on?
Your answer
Hydration & Beverages
Daily Water Intake (oz)
Your answer
What other beverages do you regularly consume?
Juices
Soda
Coffee
Tes
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If other, please specify
Your answer
Lifestyle & Energy
How many times per week do you eat out?
Once
Twice
Weekly
Once a Monthly
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Where do you usually eat out?
Your answer
Average cost per meal ($)
Your answer
On a scale of 1–10, how would you rate your energy level?
1
2
3
4
5
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Areas of Focus
Core Nutrition / Weight Management
Digestive Health
Stress Management
Immune Health
Heart Health
Healthy Aging
Men’s Health
Women’s Health
Children’s Health
Energy & Fitness
Outer Nutrition
Sports Nutrition
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Measurements (Optional / Coach Use)
Body Measurements (inches)
Body Mass Index (BMI)
Body Fat Percentage
Body Type
Basal Metabolic Rate (BMR)
Fat Mass (FM)
Fat-Free Mass (FFM)
Total Body Water (TBW)
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Form completed by
Member
Staff
Other:
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Wellness Goals & Measurements
baseline
Other:
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Submit
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