Profectus Performance
Profectus Assessment
Name
First
Last
Email
How do you want to be contacted?
Email
Phone
Text
Other
In general, what are your goals? Check all that apply.
Losing weight/fat
Gain Weight
Maintain Weight
Improve lifestyle habits
Add Muscle
Improve physical fitness
Look Better/ Feel Better
Get control of eating habits
Improve athletic performance
Please list all of your concerns about your health, eating habits, fitness, and/or body.
Out of all of the above concerns, which ones feel most important / urgent?
What are you prepared to do to work toward your goals?
Have you tried anything in the past to change your habits, fitness, nutrition? If so, what, and which things worked and didn't work well for you?
Until now, what has blocked you or held you back from changing these things?
Right now, how would you rank your overall nutrition/fitness habits?
Please enter a value between
1
and
10
.
1=Horrible 10=Awesome
Are you regularly active in sport and / or exercise? If so, approximately how many hours per week?
Select One
Fewer than 5 hours
5-9
10-14
15-19
20 or more
What's your health like?
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and /or injuries?
Yes
No
Right now, do you have any specific health concerns, such as illnesses, pain, and / or injuries?
Yes
No
Right now, are you taking any medications, either over-the-counter or prescription?
Yes
No
On a scale of 1-10, how would you rank your health right now?
Select One
1
2
3
4
5
6
7
8
9
10
1=worst 2=awesome
Given all the demands of your life, what is your typical stress level on an average day?
Select One
1
2
3
4
5
6
7
8
9
10
1=no stress 10=extreme stress
On average, how many hours per night do you sleep?
Select One
4 hours or fewer
5 hours
6 hours
7 hours
8 hours
9 hours
10 or more hours
How do you normally cope with your stress?
How READY, WILLING, and ABLE are you to change your behaviors and habits?
Select One
1
2
3
4
5
6
7
8
9
10
1=not at all 10=completely
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