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Questionnaire

The intent of this questionnaire is to get to know our clients and to help them engage in a healthier lifestyle.

First & Last Name

Email Address(Required)

Phone Number

What physical activities or sport did you enjoy as a child, or have always wanted to try?

Dodgeball

Hockey

Basketball

Kickball

Baseball

Football

Golf

Martial arts

Swimming

Rowing

Running

Dance

How would you describe your current level of physical activity on a typical week?

Inactive

Moderate

Active

Highly active

Other activities?

Let us know any other activities we can consider.

Do you prefer activities that are low intensity and relaxing, moderate and steady, or high intensity and challenging?

Low intensity and relaxing

Moderate and steady

High intensity and challenging

Would you rather engage in activities alone, with a partner, in small groups, or in larger community gatherings?

Alone

With a partner

In small groups

In larger community gatherings

On a scale of 1-10, how competitive do you consider yourself to be?

Are you drawn more to indoor activities where conditions are controlled, or outdoor adventures where you can connect with nature?

Indoor activities

Outdoor adventures

Do you take sleep aids?

Yes

How much sleep do you get on average?

Do you suffer from acid reflux?

Yes

Do you take a probiotic supplement?

Yes

What supplements are you currently taking?

What time of the day do you need a pick me up or feel unfocused?

Does Alzheimer's run in your family?

Yes

Do you have any food allergies?

Have you ever suffered from brain trauma?

Yes

Do you ever suffer from anxiety, if so how often? Or depression?

Email & Text Marketing(Required)

Yes, I agree to receive communications via email and text.

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