Optimal Wellness Survey - Cobb Wellness and Aesthetics

Name: *

Wnat is your date of birth? Month-Day-Year

What is your gender?

Male
Female

What medications are you taking?

What supplements are you taking?

Do you have any medical condition or concerns what we should know about?

Do you have any gut issues like irritable bowel or Crohn's disease?

Yes
No

Have you ever been diagnosed with cancer?

Yes
No

If yes, what kind of cancer and what was your trearment?

Are you taking hormone replacement (sex hormones and/or thyroid hormone replacement?

Yes
No

If yes, what are you taking?

If yes, do you feel good with what you are taking?

Yes
No

If no, are you interested in starting a hormone program?

Yes
No

Do you suffer from anxiety or depession?

Yes
No

If so, are you on a treatment plan?

How often do you consume alcohol?

Never
Less then twice a week
2-4 times a week
5 or more days a week

Are you interested in cutting back on alcohol consumption?

Yes
No
Maybe

How would you describe how you feel about you current body shape?

I am happy with where I am
I wish I had more muscle
I would like to be more lean
I would like to gain weight

What is your relationship to exercise and physical activity?

Don’t do it much
Don’t do it much, but I am active
Fairly new to it, but I love it
I do it, but I don’t love it
Love it, I have been exercising for years

How often do you exercise in a week?

Less than once a week
1-2 times a week
3-4 times a week
5 or more times a week

What type of exercise do you do?

What other exercise do you do?

Are you interested in fat and/or weight loss?

Yes
No

If so, how much are you looking to lose?

How many hours of sleep per night do you get?

Do you wake up feeling rested and restored?

Yes
No

Do you feel stressed?

Yes
No

What kind of stresses are you dealing with?

Do you have an injury or aches in your joints?

Yes
No

Is it easy for you to recover from a workout?

Yes
No

If not, how long does it take you to recover?

Do you have any gut issues like Crohn's or Colitis or suffer from bloating?

Do you suffer from brain fog?

Yes
No

What would you like to improve?

Do you confirm that you have answered all questions truthfully? *

Yes