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Powell Performance - Intake Questionnaire
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Address
*
Your answer
Phone number
Your answer
Preferred Time to meet with the coaching staff?
*
Afternoon
Evening
Weekends
Other:
Age in years
Your answer
What is your height in inches?
Your answer
What is your weight in pounds
Your answer
What is your biological gender?
Biological male
Biological Female
Other:
Clear selection
What is your most important goal?
Lose weight
Improve athletic performance
Gain weight
Maintain weight but improve body composition
Look and feel better
Be more consistent (stop yo-yo dieting)
Get off meds you are currently taking due to your weight or diet
Recomposition to reduce fat while staying approximately the same weight
Other:
Clear selection
Are you an athlete? This includes active duty members getting ready for selection, ACFT prep, Ranger school, etc.
Yes
No
Clear selection
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