Proactive mobility optimal health Data survey

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Optimal Health Data Survey

Section 1 - Identity Snapshot

Full Name *

Date of birth *

Phone *

Email *

Gender

Occupation

Section 2 - Goal Setting & Motivation

What are your top 3 goals for your health, body, or energy right now?

On a scale of 1–10, how committed are you to reaching those goals?

What will it cost you if you don’t achieve them?

What’s worked for you in the past?

What’s failed you in the past?

What’s the #1 reason you haven’t already hit your goals?

Who else will benefit if you get this right?

What are 3 - 5 words or phrases that you would like to describe your future self.

my future self is ...
my future self is ...
my future self is ...
my future self is ...
my future self is ...

Section 3 - Body Data & Biometrics

Current Weight

Goal Weight (if applicable)

Current Body Fat %

Body Fat % Goal (if applicable)

Do you use a wearable tracking device (Oura, WHOOP, Apple Watch, etc.)

📎 Attach most recent InBody/Evolt PDF here

Section 4 - Clinical Data & Labs

Have you had recent blood work done in the last 6 months? (Y/N)

Yes

No

Can you upload or send results? (Upload option)

Are you currently being treated for any medical condition? (Y/N, with freeform box)

Yes

No

If yes please describe

Are you taking any medications or supplements?

Section 5 - Nutrition & Digestive Health

On average, how many meals do you eat per day?

Do you track your food? (Y/N)

Yes

No

Do you have any known food allergies/sensitivities?

Yes

No

How’s your digestion? (Check all that apply)

How often do you drink alcohol?

Do you have any emotional eating or challenges with cravings?

Yes

No

How many glasses of water do you drink per day?

Any current dietary style? (Check all that apply: Keto, IF, Paleo, Vegan, etc.)

Please list all meds and supplements you are currently taking.

Section 6 - Training, Movement, Mobility

Current weekly activity level (None / Light / Moderate / High)

How many days per week are you moving/exercising now?

What kinds of training do you enjoy? (Check all: weights, HIIT, bands, yoga, cardio, walking, etc.)

Do you currently follow a structured training plan? (Y/N)

Yes

No

Any injuries, limitations, or pain points?

Are you currently seeing a PT, chiro, or massage therapist? (Y/N)

Yes

No

Section 7 - Sleep, Energy, Recovery

How many hours of sleep do you average?

Do you have trouble falling asleep or staying asleep?

Yes

No

What is your energy like...

Morning
Afternoon
Evening

How do you currently recover after exercise or exertion? (e.g., sleep, stretching, cold plunge, massage, nothing, etc.) Check all that apply

Do you take naps, or feel like you need one? (Y/N)

Yes

No

Have you used or are you familiar with any of the following. (Check all that apply)

Section 8 - Stress, Mindset & Support

Top 3 stressors in life right now?

How do you usually handle stress? (Eat, shut down, work out, breathe, pray, etc.)

Do you meditate or journal? (Y/N)

Yes

No

Who supports your health goals? (Partner, coach, no one, friends, etc.) Check all that apply

Are you open to working on mindset and mental fitness? (Y/N)

Yes

No

What’s one belief you know you need to change to become who you want to be?

Section 9 - Logistics & Coaching

If you were to hire a coach what is your preferred coaching style?

Preferred contact method

Anything else you would like to share with us that you think would help us help you reach your goals?

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