This questionnaire helps us understand your current health, daily habits, and what you’re looking for from a longevity-focused coaching program. We review every response personally so we can decide together whether this is the right fit and what level of support makes the most sense.

None of this is about perfection; it’s about getting an honest snapshot of where you are right now so we can build from there. Please answer as fully and honestly as you can—there are no “right” or “wrong” answers.

This form is for coaching purposes only and does not replace medical care. You should continue to work with your medical providers and clear any new exercise, nutrition, or lifestyle changes with them as needed.

section A - client details

section b - medical history and safety

section c - pain, injuries, and movement

section d - daily habits and lifestyle

section e - nutrition

section f - social support and environment

section g - goals, mindset, and readiness

section h - services, logistics and consent