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Fitness Consulting Intake Form
Fitness Consulting - Intake
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What is your name?
Your answer
What is your email address?
Your answer
Sex
Male
Female
Prefer not to say
Clear selection
What is your chronological age?
Your answer
How old do you feel?
Your answer
If you were to guess, how many years do you think that you will live? (lifespan)
Your answer
If you were to guess, how many years do you think that you will enjoy good health? (healthspan)
Your answer
Please describe any major health events that have occurred in your life, such as major surgeries, illnesses, traumatic events, etc. In particular, consider those that may have occurred in your youth. (youth defined as < 25 years of age)
Your answer
On average, how many minutes
per week
do you spend working out?
< 30 minutes
30-50 minutes
51-100 minutes
101-150 minutes
151-200 minutes
> 201 minutes
Clear selection
Approximately how many minutes
per week
do your workouts have you breathing hard and/or sweating?
< 30 minutes
30-50 minutes
51-100 minutes
101-150 minutes
151-200 minutes
> 201 minutes
Clear selection
On average, how many hours do you sleep per night? (do not count daytime naps)
< 7 hours per day
7 - 9 hours per day
> 9 hours per day
Clear selection
How would you characterize the quality of your sleep? (scale from 1 - 10, with 1 being the worst and 10 being the best quality sleep)
Terrible quality sleep
1
2
3
4
5
6
7
8
9
10
Sleep soundly most nights
Clear selection
Do you currently use a wearable such as an Apple Watch, Garmin or FitBit?
Yes
No
Clear selection
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