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Lifestyle Assessment
Please answer these questions as best as you can. This will help us curate a plan that best fits you and your lifestyle goals.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Gender
*
Female
Male
Date of Birth
*
MM
/
DD
/
YYYY
Ethnicity
Caucasian/White
African American/Black
Hispanic/Latino
Asian/Pacific Islander
Native American/American Indian
Other:
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Phone Number
*
Your answer
Your Goal
*
Maintain Weight
Lose Weight
Gain Weight
Other:
Are you taking blood pressure medications
*
No
Yes
Have you been diagnosed with prediabetes, type 1 diabetes, or type 2 diabetes?
*
Type 1 diabetes
No
Prediabetes
Type 2 diabetes
Required
Are you taking medications for your cholesterol levels?
*
Yes
No
Please list any pre-existing medical conditions you have been diagnosed with in the past
*
Your answer
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