Inquiry Register Form

What is your sex?

Male

Female

*This question refers to your biological sex and not your gender identity. In general, the response that will generate the most accurate results is the sex that you were assigned at birth. If you are unsure of your response, remember that you can always repeat the assessment using an alternate response.

What is your height?

(Feet)

4

5

6

What is your date of birth?

What is your zip code?

Waist Circumference (Inches)

Don’t know your waist size?
Refer to the guide below or use a tape measure.
If measuring waist, center tape over belly button.

Current Weight (Pounds)

Highest Adult (Non-Pregnancy) Weight (Pounds)

What is your level of muscularity?

Very High

High

Average

Low

In your own words, describe in one sentence your deepest and most meaningful reason for wanting to work on your fitness and weight now (your “Why”).

Is this your truest “Why” or is there a deeper reason?

No, let me try again

Yes, I’m happy with this reason

Why are you interested in taking action NOW to address your fitness and/or nutrition? Select one

Upcoming event

Health professional recommendation

Recent weight gain

Recent inactivity

Recent stress level

Recent sleep issues

Recent health issue

Recent relocation

Recent injury

Looking for new approach

Referral from friend

Other

Please characterize your participation in consistent, planned exercise across the past year on average.

Exercise less than 3 days per week for 30 minutes or more

Light exercise 3 or more days per week for 30 minutes or more

Moderate exercise 3 or more days per week for 30 minutes of more

Intense exercise 3-5 days per week for 30 minutes or more

Intense exercise 6-7 days per week for 30 minutes or more

Please select the response that best characterizes your weight goal.

Maintain current level of body fat

Lose 1-10 pounds of body fat

Lose 11-20 pounds of body fat

Lose 21-30 pounds of body fat

Lose 31-40 pounds of body fat

Lose 41-50 pounds of body fat

Lose 51-75 pounds of body fat

Lose 76-100 pounds of body fat

Lose over 100 pounds of body fat

Please select the response that best characterizes your fitness goal.

Maintain current level of fitness

Small improvement in level of fitness

Moderate improvement in level of fitness

Large improvement in level of fitness

Very large improvement in level of fitness

On a scale of 0 to 5, with 5 being most important and 0 being least important, please indicate the level of importance of each item below to your desire to improve your fitness and weight.

Health & Wellness

Appearance & Self-Esteem

Social Engagement

Performance

On a scale of 0 to 5, with 5 being most challenging and 0 being least challenging, please score the level of challenge that you face from each item below in achieving your fitness and weight goals.

Time & Schedule

Motivation & Support

Goal-Setting & Structure

Fitness & Nutrition Knowledge

On a scale of 0-5, with 0 being lowest and 5 being highest, how would you characterize your level of unhealthy stress in the following settings:

Work or School: (drop down response 0-5)

Home: (drop down response 0-5)

Social Engagements: (drop down response 0-5)

Recent/Chronic Injuries and Medical Events

Back Injury

Sciatica

Knee Injury

Hip Injury

Elbow Injury

Wrist Injury

Ankle Injury

Fracture

Dislocation

Shin Splints

Bursitis

Muscle or Ligament Tear

Recent Surgery

Delivery/Pregnancy

Shoulder Injury

Other (Click to enter)

NONE

Scroll Through List And Select ALL Diagnosed Conditions That Apply To You.

High Blood Pressure

High Cholesterol

High Triglycerides

Acid Reflux/Heartburn/Indigestion

Back Pain

Joint Pain

Fatigue/Low Energy

Shortness of Breath Under Exertion

Irritable/Irregular Bowel

Adult Acne

Frequent Headaches

Frequent Muscle Aches

Muscle Twitching or Cramps

Frequent or Lengthy Colds

Constant Feelings of Stress or Anxiety

Frequent Sugar Cravings

Daytime Drowsiness

Brain Fog/Poor Concentraion

Frequent or Easy Bruising

Depression

High Blood Sugar/Prediabetes

PCOS

Hyperuricemia

Irregular Cycle/Infertility

Sleep Apnea

Poor Circulation

Restricted or Limited Mobility

Edema/Swelling

Slow Healing

Uncontrolled Eating/Food Addiction

Non-Age Memory Loss

Non-Age Cognitive Decline

Jaundice (yellowed skin)

Low Kidney Function (including Dialysis)

Type 2 Diabetes

Fatty Liver

Heart Disease

Gout

Gallstones

Osteoarthritis

Neuropathy

Gangrene and/or Amputation

Early Onset Alzheimers

History of Stroke

History of Endometrial Cancer

History of Esophogeal Cancer

History of Gastric Cancer

History of Liver Cancer

History of Kidney Cancer

History of Pancreatic Cancer

History of Colorectal Cancer

History of Meningioma (Brain Cancer)

History of Multiple Myeloma (Blood Cancer)

History of Gall Bladder Cancer

History of Ovarian Cancer

History of Post-Menopausal Breast Cancer

History of Throid Cancer

NONE

How many commercial diet plans have you followed (for at least 30 days) in the last five (5) years?

20+ diet plans followed

15-19 diet plans followed

10-14 diet plans followed

6-9 diet plans followed

3-5 diet plans followed

1-2 diet plans followed

0 diet plans followed

Your current level of overall fitness for your age is:

Very Low

Low

Moderate

High

Very High

What supplementation do you take regularly? (check all that apply)

I do not take supplements

Multivitamin

Apple Cider Vinegar

Ashwagandha

BCAAs

Borage

Calcium

CBD

Chondroitin

Chromium

Cinnamon

Coconut Oil

Collagen

CoQ10

Creatine

Curcumin/Tumeric

Digestive Enzymes

Fish Oil/Krill Oil/Algae Oil/Omega-3

Flaxseed

Folic Acid

Gingko

Ginseng

Glucosamine

Green Tea Extract

Iron

L-Arginine

L-Carnitine

Magnesium

Manganese

Melatonin

Milk Thistle

Niacin

Potassium

Pre-Workout

Probiotics

Protein Powder

Resveratrol

Selenium

St. John’s Wart

Taurine

Tyrosine

Valerian

Vitamin B Complex

Vitamin B12

Vitamin C

Vitamin D

Vitamin E

Vitamin K

Zinc

Other

What fitness activities have you enjoyed (in the past?)?” (check all that apply)

Aerobics

Barre

Basketball

Body Weight Exercise/Calisthenics

Bootcamp

Boxing

Circuit Training

Dance

Golf

Gymnastics

HIIT

Hiking

Indoor Cycling

Jogging or Running

Jumping Rope

Kickboxing

Martial Arts

Outdoor Cycling

Pilates

Racquetball

Rock Climbing

Rowing

Skiing

Soccer

Squash

Stair climber

Step Aerobics

Stretching

Swimming

Tai Chi

Tennis

Volleyball

Walking

Water Aerobics

Weight Lifting

Yoga

Other

When do you prefer to workout? Select all that apply

Monday	Morning	Afternoon	Evening
Tuesday	Morning	Afternoon	Evening
Wednesday	Morning	Afternoon	Evening
Thursday	Morning	Afternoon	Evening
Friday	Morning	Afternoon	Evening
Saturday	Morning	Afternoon	Evening
Sunday	Morning	Afternoon	Evening

How often to you smoke tobacco or use a vaporizer?

Daily

Occasionally

Never

Which of the following recovery practices do you engage in on a consistent basis following exercise?

Foam Rollers

Percussive Therapy Guns

Heat Therapy (Such as Steam and Sauna)

Light Therapy (Such as Infrared and Red Light)

Cold Therapy (Such as Cryotherapy or Cold Packs)

Compression Therapy

Hyperbaric Therapy or Floatation Therapy

None

First Name

Last Name

Email

Mobile Number

State

Country

City

Location

Create Password

Confirm Password

What is your sex?

What is your sex?

What is your height?

What is your height?

(Feet)

(Inches)

What is your date of birth?

What is your zip code?

Waist Circumference (Inches)

Current Weight (Pounds)

Highest Adult (Non-Pregnancy) Weight (Pounds)

What is your level of muscularity?

What is your level of muscularity?

In your own words, describe in one sentence your deepest and most meaningful reason for wanting to work on your fitness and weight now (your “Why”).

Is this your truest “Why” or is there a deeper reason?

Is this your truest “Why” or is there a deeper reason?

Why are you interested in taking action NOW to address your fitness and/or nutrition? Select one

Why are you interested in taking action NOW to address your fitness and/or nutrition? Select one

Please characterize your participation in consistent, planned exercise across the past year on average.

Please characterize your participation in consistent, planned exercise across the past year on average.

Please select the response that best characterizes your weight goal.

Please select the response that best characterizes your weight goal.

Please select the response that best characterizes your fitness goal.

Please select the response that best characterizes your fitness goal.

On a scale of 0 to 5, with 5 being most important and 0 being least important, please indicate the level of importance of each item below to your desire to improve your fitness and weight.

On a scale of 0 to 5, with 5 being most important and 0 being least important, please indicate the level of importance of each item below to your desire to improve your fitness and weight.

On a scale of 0 to 5, with 5 being most challenging and 0 being least challenging, please score the level of challenge that you face from each item below in achieving your fitness and weight goals.

On a scale of 0 to 5, with 5 being most challenging and 0 being least challenging, please score the level of challenge that you face from each item below in achieving your fitness and weight goals.

On a scale of 0-5, with 0 being lowest and 5 being highest, how would you characterize your level of unhealthy stress in the following settings:

On a scale of 0-5, with 0 being lowest and 5 being highest, how would you characterize your level of unhealthy stress in the following settings:

Recent/Chronic Injuries and Medical Events

Recent/Chronic Injuries and Medical Events

Scroll Through List And Select ALL Diagnosed Conditions That Apply To You.

Scroll Through List And Select ALL Diagnosed Conditions That Apply To You.

How many commercial diet plans have you followed (for at least 30 days) in the last five (5) years?

How many commercial diet plans have you followed (for at least 30 days) in the last five (5) years?

Your current level of overall fitness for your age is:

Your current level of overall fitness for your age is:

What supplementation do you take regularly? (check all that apply)

What supplementation do you take regularly? (check all that apply)

What fitness activities have you enjoyed (in the past?)?” (check all that apply)

What fitness activities have you enjoyed (in the past?)?” (check all that apply)

When do you prefer to workout? Select all that apply

When do you prefer to workout? Select all that apply

How often to you smoke tobacco or use a vaporizer?

How often to you smoke tobacco or use a vaporizer?

Which of the following recovery practices do you engage in on a consistent basis following exercise?

Which of the following recovery practices do you engage in on a consistent basis following exercise?

Waist Size Guide