SYXGEN Health Status Form
This 10-20 minute form is the first step in understanding your total health picture. By completing it, you will allow us to analyze your individual needs, while also being prompted for things you might have not known could be addressed!
Email address *
Are you currently working with any of our coaches?
Were you referred by any of our online affiliates?
Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Height (inches) *
For this measurement, your height MUST be selected in inches. (Ex. 5'0" = 60" and 6'0" = 72" , etc.)
Current Body Weight (lbs) *
Your answer
Goal Weight *
Your answer
Abdominal Circumference (inches)
Greatest circumference around your midsection between your ribs and your hips
Your answer
What is your blood type? *
What is your Blood Pressure? (mm/Hg)
Make sure you have been seated for at least 5 minutes before measurements are taken
Your answer
What is your Resting Heart Rate? (bpm) *
Make sure you have been seated for at least 5 minutes before measurements are taken
Your answer
Do you have a wrist-based activity tracker? *
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