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Health & Goals Questionnaire

Birthday
Month
Day
Year

Personal Health & Goals

How important is improving your energy, recovery, and overall health?
Do you struggle with memory, focus, or concentration?
Do you experience increased body fat, especially around the midsection?
Do you struggle with poor sleep quality or frequent waking during the night?
Do you experience brain fog, sluggishness, or lack of motivation?
Have you noticed decreased muscle mass, slower recovery, or loss of strength?
Do you experience chronic fatigue, low stamina, or frequent “energy crashes”?

Recovery & Resilience

Do you feel like you recover slower than normal from workouts, injuries, or illness?
Have you experienced slower healing from surgeries, infections, or general illness?
Do you experience prolonged soreness or inflammation after exercise?
Do you suffer from chronic inflammation, autoimmune issues, or allergies?

Immune & Detox Support

Do you get sick often or feel like your immune system is weaker than it used to be?
Are you regularly exposed to environmental toxins (alcohol, smoking, workplace chemicals)?
Do you have a history of liver concerns (fatty liver, hepatitis, detox issues)?
Do you drink alcohol regularly or have a history of alcohol use disorder?

Longevity & Aging Concerns

Do you want support with healthy aging, cellular repair, and long-term wellness?
Yes
No
Do you have skin concerns such as dull complexion, hyperpigmentation, or premature aging?
Are you concerned about aging-related decline, longevity, or performance?

Medical History & Safety

Are you currently taking any prescription medications, supplements, or GLP-1s?
Yes
No
Do you have any major medical conditions (cancer, autoimmune disease, cardiovascular disease)?
Yes
No
Do you have a history of neurodegenerative conditions (e.g., Alzheimer’s, Parkinson’s)?
Yes
No
Have you been diagnosed with metabolic issues (pre-diabetes, insulin resistance, obesity)?
Yes
No
Do you currently have untreated sleep apnea or uncontrolled diabetes?
Yes
No
Are you currently pregnant, breastfeeding, or undergoing chemotherapy?
Yes
No

PARQ (Physical Activity Readiness Questionnaire)

Have you been hospitalized in the last 12 months?
Yes
No
Are you currently suffering from a medical condition, illness, or injury?
Yes
No
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommend by a doctor?
Yes
No
Do you feel pain in your chest when you perform physical activity?
Yes
No
In the past month, have you had chest pain when you are not performing physical activity?
Yes
No
Do you lose balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem that could be made worst by a change in your physical activity?
Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Yes
No
Do you know of any other reason why you should not engage in physical activity?
Yes
No

If you answered yes to one or more of the above PARQ (Physical Activity Readiness Questionnaire) questions, consult your medical doctor or physician before engaging in physical activity. After medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. Attach below a medical doctor or physician's note authorizing physical activity.

Lifestyle Questionnaire

What is your current salary range?
less than $100,000
$100,001-$150,000
over $150,001
Does your occupation require extended periods of sitting?
Yes
No
Does your occupation cause you anxiety (mental stress)?
Yes
No

Health Declaration

Are you experiencing any flu or flu-like symptoms?
Yes
No

Authorization

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Date
Month
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