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Peak Performance Wellness Center
Lifestyle Assessment Form
If a question does not pertain to your reason for scheduling an appointment, enter "NA" for your response
First Name
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Last Name
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Phone Number
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Email Address
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Birthday (mo/day/year)
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If you have a diagnosis or core issue you would like to work on list it below.
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List the primary symptom that goes with your diagnosis or core issue. Include when it started, which organ(s) is involved and what was going on in your life around the time it started.
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If you have a secondary symptom you would like to focus on list it below.
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List traumatic or shocking events throughout your lifetime and appropriate dates.
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If you take prescription medications, list each below along with how long you have taken each.
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If you take supplements, list them below.
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List any surgeries you have had.
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How many ounces of water do you drink each day? *
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What kind of water do you drink? *
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Reverse Osmosis
Distilled
Tap
Spring
Filtered
How much sweaty activity do you participate in weekly?
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How often do you eat out?
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How many alcoholic beverages do you consume each week?
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Do you smoke?
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Yes
No
List everything you had to drink/eat yesterday.
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What time do you go to bed?
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What time do you wake up in the morning?
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How is your energy level?
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How much time do you spend outside each week?
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Please list any family health history that you feel would be good for me to know.
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What would you like to focus on during your 1-1 consultation?
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Is there anything I have not asked about that you would like for me to know?
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Details for Your Appointment
To prepare for the scan that will take place during your appointment, please follow these guidelines:
Drink 8 ounces of water throughout the hour before your appointment.
No alcohol 12 hours before your appointment.
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