LIT Health Intake Form

Welcome to LIT Health! In order for us to properly coordinate your next steps, please complete the following survey questions in full.

Please answer these questions truthfully – we don’t judge how much or how little you weigh, eat, or exercise! This information helps us know where to start you in our program and gauge where you can be at the end of YOUR journey. Thank you!

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Current Height(Required)

Current Weight (or best guess)(Required)

What is your date of birth?(Required)

MM slash DD slash YYYY

What is your current age?(Required)

Describe your daily diet; include foods you eat regularly, your calorie intake if you know it, and perhaps any dietary program you are currently following.(Required)

How many 30-60 minute workout sessions can you currently fit within your weekly schedule?(Required)

What is your profession and how physically active are you during the day?(Required)

Have you ever trained formally before?(Required)

Yes

Other

If you exercise now, what type of exercises do you do? And for how long?(Required)

Do you smoke, drink alcohol, consume marijuana or any other substances? If so, describe your usage (how much and how often).(Required)

Do you have any pre-existing medical conditions? Be as exhaustive as you can.(Required)

Are you currently taking any medications? If so, what are they?(Required)

What are your fitness goals? These can include physical, psychological, and/or other wellness milestones you hope to achieve. If you are unsure, please share why you are interested in working together.(Required)

Do you have fitness or nutrition influencers / regimens that you follow?(Required)

How recently have you completed lab work via a blood and/or urine test?(Required)

Within a year from now

Between a year and two years ago

More than two years ago

Is there anything else we should know before we create a personalized plan for you?(Required)

We focus on the whole person and want to be able to support you in any way we can. Is there anything else you haven't shared that you hope to gain from this journey?(Required)

How did you hear about us?

Comments

This field is for validation purposes and should be left unchanged.

LIT Health Intake Form

Welcome to LIT Health! In order for us to properly coordinate your next steps, please complete the following survey questions in full.

Please answer these questions truthfully – we don’t judge how much or how little you weigh, eat, or exercise! This information helps us know where to start you in our program and gauge where you can be at the end of YOUR journey. Thank you!

"Every individual deserves the opportunity to invest in their health and wellness."