Lifestyle Intake Form Please Complete The Form As Accurately As Possible Lifestyle Intake Form First Name Last Name Date of Birth Email Phone Address Gender Male Female Height Weight What are your goals? Check all that apply. Lose weight / fat Gain weight Maintain weight Get healthier Get control of eating habits In order of importance, please list all of your concerns about your health, eating habits, fitness, and/or body. Approximately how many hours a week do you exercise? 0-2 3-5 5-8 8 or more Approximately how many hours a week do spend outdoors? 0-2 3-5 5-8 8 or more How many glasses of water do you drink per day? 0-1 2-4 4-6 6 or more On average, how many hours per night do you sleep? 4 or less 5-6 6-8 8 or more What is your typical stress level? 1. None 2. Low 3. Moderate 4. High 5. Extreme How do you manage your stress? Have you been diagnosed (currently or in the past) with any significant medical conditions and/or injuries? Yes No If you answered yes to the previous question, please describe. Please list all prescribed medications or supplements. Please describe your level of spirituality (prayer, meditation, etc..) None Somewhat religious/spiritual Very religious/spiritual If you are human, leave this field blank. Submit