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Full Name

Email *

Phone (optional)

Date of birth

1. How often do you exercise per week?

5+ times (mix of cardio and strength)

3-4 times (some movement weekly)

1-2 times (light activity)

Rarely or never

How would you describe your diet?

Whole-foods based, balanced, low processed foods

Fairly balanced, but with some processed items

High in processed foods, sugar, or takeout

Mostly junk food or irregular eating habits

How often do you smoke or use tobacco/nicotine products?

Never

Occasionally (socially)

Regularly (but trying to quit)

Daily (no plans to quit)

How is your stress management?

Great – I use tools like meditation, breathwork, etc.

I manage, but stress builds up

Frequently overwhelmed

Constantly stressed and anxious

What’s your average sleep duration per night?

7–9 hours

5–6 hours

4–5 hours

Less than 4 hours

Do you know your blood pressure?

Yes, normal and stable

Slightly elevated

High and monitored

Very high or unknown

Do you have a family history of heart disease?

No history

One family member

Multiple relatives

Immediate family member + symptoms yourself

What’s your current waist size or body composition?

Within a healthy range (waist under 40in men / 35in women)

Slightly above recommended range

High visceral fat or overweight

Obese or at-risk body type

How often do you consume alcohol?

Rarely or occasionally

Socially (1–2x/week)

Frequently (3–5x/week)

Daily or binge drink

When was your last full health check-up?

Within the past year

1–2 years ago

Over 2 years ago

I've never had one