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AdonnasFitnessRoom Preliminary

"Healthspan" Questionnaire

Gender
Female
Male
Non-Binary
Age
30-39
40-49
50-59
60-69
70-79
80+

Medical History:

Do you have any chronic medical conditions? (e.g. diabetes, hypertension, asthma etc.)

Multi choice

Have you had any surgeries in the past?

Multi choice

Are you currently taking any medications or supplements?

Multi choice

Do you have any known allergies? (e.g. medications, foods, environmental)

Multi choice

Do you have a family history of any significant medical conditions? (e.g. heart disease, cancer, diabetes etc.)

Multi choice

Lifestyle and Habits:

How often do you exercise?

Multi choice

List the types of exercise and the duration:

How would you describe you diet?

Multi choice

Do you follow any specific diet? (e.g. paleolithic, keto, vegetarian, vegan, low-carb)

Multi choice

Do you smoke?

Multi choice

Do you consume alcohol?

Multi choice

If regularly, how many drinks per week?

How many hours of sleep do you get on average per night?

Multi choice

How would you rate your stress level?

Multi choice

General Health:

Do you experience any of the following regularly? (Check all that apply.)

Multi choice

When was your last medical check-up?

Multi choice

Have you received any vaccinations recently? ( e.g. Flu shot, Covid 19)

Multi choice

Fitness Goals:

Check all the items below that are important for you to address.

Health Goals:

Check all the items below that are important for you to address.

Multi choice

Thank you for completing this preliminary "healthspan" questionnaire. The information gathered is strictly confidential and will not be shared. If you have any questions please forward them to the email address.

Now let's get you on your way to improving your HEALTHSPAN!!!!

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