Fill out the Health Survey Form

Tell us about your health goals and choose a time to talk - we'll follow

up with next steps.

First name

Last name

Phone number

What services are you interested in learning more about?

1. What is one thing you wish you could change about your health today?

2. What are a few things about your health (physically or mentally) that you are not satisfied currently, but you believe can improve over time?

3. If you do not currently exercise on a consistent basis, what are some of the things that may be holding you back (eg. Busy work schedule, taking care of kids or family responsibilities, lack of motivation to exercise, unsure of where to start)?

4. What kind of physical activities or movements do you perform currently on a weekly basis (eg. walking, jogging, sprinting, weight lifting, swimming, core strength, isometrics)?

5. What are some physical exercises that you may enjoy performing on a weekly basis? (eg. Push ups and pull ups, sprinting, calisthenics, swimming, weight lifting, Pilates, ab and core workouts, walking stairs, jump rope, etc.)

6. Do you currently belong to a gym? Where do you currently workout and exercise?

7. What are some foods and drinks that you like to consume on a weekly basis?

8. What are some healthy foods that you enjoy eating on a weekly basis (eg. fruits and vegetables, eggs, avocado, steak, turkey or chicken, hummus, etc.)

9. What are some foods or drinks that you are consuming that would be better if you eliminated them from your diet?

10. Do you consume alcohol on a weekly or monthly basis?

11. Do you currently use any tobacco products? Do you vape?

12. How much sleep (on average) do you get per night? What time do you typically go to bed and what time do you wake up?

13. Do you watch television in your bedroom? Are you on your cell phone or laptop while in bed before you go to sleep?

14. What kind of work do you do? Are you sitting down in a chair for most of the day or does your job require you to move your body for the majority of the workday?

15. How many hours a day do you work? How many days out of the week do you work?

16. What are some hobbies of yours that you enjoy (eg. Reading, hiking, playing a musical instrument, rock climbing, dancing, playing sports, etc.)

17. What is one hobby (or skill) you would love to pick up and engage in over the next few months?

18. Tell me something about yourself that makes you proud or gives you a sense of joy?

19. What is one thing in your past, where you took on a challenge and you were happy with your effort and what you accomplished?

20. What is one challenge in the future that, if you accomplished, would give you a sense of pride or joy?

What's your timeline or preferred start date?

Schedule an appointment

Jul - Aug 2026

Week starting Sunday, July 26

Time zone: Coordinated Universal Time (UTC)Phone call

Tuesday, Jul 28

10:00 AM - 11:00 AM

11:00 AM - 12:00 PM

12:00 PM - 1:00 PM

1:00 PM - 2:00 PM

Health Forms