First Name:
Last Name:
Email:
Do you experience any of the following; brain fog, headaches, brain fatigue, cognitive overload, decision fatigue, or memory loss (short or long-term)?
What are your present concerns about your overall health and longevity? List all that you can think of.
What does your current diet consist of? List all food, beverages, snacks, and frequency.
Are you presently taking any supplements or medications, and are there any medications you would like to try to discontinue (i.e. blood pressure or cholesterol medications)? List all that apply.
What is your current exercise or fitness routine? And what do you desire it to be instead, if applicable?
Describe your current quality of sleep and general duration of sleep per night. If applicable, what do you think is the source of any challenges you're experiencing?
What is the one area of your health you would most like to improve?
What are your biggest goals in life? List as many as you can think of.
What do you love to do in your free time, and what could you see yourself doing every day of your life for the next 20 years?
Doing _____ makes me the happiest. List anything you can think of.
What do you personally struggle with the most? This could be anything, not just health-related.
What would you like to learn in our community? List as many topics as you can think of.
What are your personal goals that you feel could be best served by our community?
What do you have to give to our community, or how do you feel you may best contribute?
How would you best describe your learning style (visual, auditory, group discussion, etc.)?
If you could live anywhere in the world, where would it be, and why?
What is your superpower, or what are you better at doing than almost anyone else?
If you had one day to live, what would you spend it doing? Who would you do it with?
Is there anything else you think would be helpful for me to know so I can offer you my highest and best service and support?
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