Lifestyle Questionnaire - Powered by Keap

Lifestyle Questionnaire

This lifestyle questionnaire is designed to help you uncover potential blind spots to your health and provide you with valuable insights into living your best life possible. As a thank you, we'll send you a Free Copy of Move with Purpose book (shipping and handling fees may apply).

First Name *

Last Name *

Phone *

Email *

Do you perform strength training exercises (with weights, such as dumbbells for example) for at least 30 minutes, 2x per week on a consistent basis? *

YesNo

Do you perform cardiovascular exercise (brisk walking, swimming or biking to increase your heart rate for example) for at least 30 minutes, 3x per week on a consistent basis? *

YesNo

Do you perform flexibility stretches to improve your mobility (yoga or stretches where you “hold” a position for example) for at least 15 minutes, 5x per week on a consistent basis? *

YesNo

Do you safely challenge your balance by performing various stabilization exercises (stand on one foot for example) for at least 5 minutes, 3x per week on a consistent basis? *

YesNo

Do you have Hearing Loss or difficulty hearing in noise? *

YesNo

Have you been experiencing increasing 'Senior Moments' or Memory Concerns? *

YesNo

Do you have Tinnitus or ringing in the ears? *

YesNo

Have you fallen recently or have a fear of falling? *

YesNo

Do you average at least 7 hours of sleep most nights? (At least 6 nights/per week) *

YesNo

Do you feel rested when you wake up most mornings? (At least 6 nights/per week) *

YesNo

Do you feel you are at a healthy weight? *

YesNo

Do you strive to eat as healthily as you know how to, at least 80% of the time? *

YesNo

Do you commonly pursue continual learning opportunities? (i.e. you have a hobby, read books daily, take continual education classes, etc.) *

YesNo

Are you a part of a community (religious, service volunteer, etc.) and connect with others face to face at least 3-4x week? *

YesNo

Do you practice Mindfulness (i.e. take extended periods of time to be silent, do mindful breathing, pray, etc.) at least 4-5x week? *

YesNo