Concierge Prevention Program Questionnaire
First Name
Last Name
Email
Address
Birthday
List your #1 goal for the next 3 years.
What are your top 3 health concerns?
Why are you doing the Tack180 testing?
What diseases run in your family?
Please describe your diet briefly.
How many times a week do you exercise?
List exercises, frequency, and duration
How many hours of sleep do you usually get?
Do you feel rested most mornings?
Select...
Yes
No
What do you do to manage stress (all)?
Select...
Yoga
Meditation
Journaling
Prayer
Exercise
Visual Imagery
Tai Chi
Other
List each stress management practice, frequency, and duration.
List your medications and supplements.
Have you done genetic testing before?
Select...
Yes
No
Not sure
Which of the following areas do you feel you need to work on most?
Select...
Sleep
Purpose/Why
Connection/Social
Stress
Activity/Fitness
Nutrition
What else would you like us to know?
How did you hear about us?
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