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FAQ
Business Title
IBE Intake Form
First name
Last name
Date of Birth
Phone
Email
Prefered Method of Contact
Call
Text
Email
What specific goals would you like to address?
How would you describe your typical daily activity level?
Sedentary (little or no exercise)
Lightly Active (light exercise 1-3 days per week)
Moderately Active (moderate exercise 3-5 days per week)
Very Active (hard exercise 6-7 days per week)
Extremely Active (very hard exercise or sports
Do you have any known medical conditions? If yes, please specify
Yes
No
Are you taking any medications? If yes, please list them
Yes
No
How many meals do you typically eat in a day?
1
2
3
4
5
How much water do you drink on an average day?
1-2 cups
2-3 cups
4-5 cups
6-7 cups
8 or more
How many hours of sleep do you get on average each night?
2 or fewer
3-4 hours
4-5 hours
6-7 hours
8 or more
Choose one
*
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