First name
Last Name
Email
Date of birth
Weight
Height
What’s your health like?
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and / or injuries?
Right now, are you taking any medications, either over-the-counter or prescription? Include neurological, sleep, behavioral, herbs, lifestyle (relaxation aids), and additional / other medication.
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
Vitality Pillar 4: Physical Recovery
These questions will explore your awareness levels within this pillar and the associated lifestyle variables.
Have you ever been given a mobility test?
Never
In the last year
Once or twice a year
Every couple months
How often have you stretched during the week outside of exercise?
Never
1 or less days a week
2 to 4 days a week
5 or more days a week
Right now, on a scale of 1 (none) to 10 (total flexibility), how would you rate your flexibility in the following areas: (1) Foot and Ankle Complex, (2) Hip and Trunk Complex, and (3) Shoulder and Neck Complex
Do you have a weekly mobility routine you follow?
No
1 or less days a week
2 to 4 days a week
5 or more days a week
How many times do you get professional recovery services, such as a sports massage, in a 30-day span?
How ready, willing, and able are you to change? Right now, on a scale of 1-10.
On a scale of 1 to 10, with 1 being not at all and 10 being completely, how READY are you to change your behaviors and habits?
On a scale of 1 to 10, with 1 being not at all and 10 being completely, how WILLING are you to change your behaviors and habits?
On a scale of 1 to 10, with 1 being not at all and 10 being completely, how ABLE are you to change your behaviors and habits?
On a scale of 1 to 10, with 1 being not at all and 10 being completely, how MOTIVATED are you to change your behaviors and habits?
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