Lifestyle Questionnaire

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Please fill out the following form to help us understand your lifestyle.

First Name

Email Address

Last Name

Date of Birth

What is your current occupation

What is your current salary range?

less than $100,000

$101,000-$150,000

over $151,000

Does your occupation require extended periods of sitting?

Yes

Does your occupation cause you anziety (mental stress)?

Yes

On average how many cigarettes do you smoke a day?

On average how many hours do you sleep per night?

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? If yes, please explain.

Have you ever had any surgeries? If yes, please explain.

Has a medical doctor ever diagnosed you with a chronic disese, such as coronary heart disease, coronary artery disese, hypertension (high blood pressure), high cholesterol, or diabetes? If yes, please explain.

Are you currently taking any medication? If yes, please explain.

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Today's Date

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Get in Touch

Email.

Phone. 617.970.3352

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