Welcome, Let's Get Started

Country of Residence (for timezone needs)*

Gender/Gender Identity

Average Sleep Per Night (hours)*

Sleep Quality*

Daily Stress Level*

How Do You Relieve Stress?

Recent Major Life Changes?*

Explain Recent Major Life Changes

Use Wearable/Trackable Devices or Apps?*

Which Devices/Apps? (e.g., Fitbit, Apple Watch, Oura Ring, Strava, MyFitnessPal)

Is there anything about your health history or current situation that would help us understand how to best support you?

Strenuous exercise: Heartbeats rapidly (E.g [throughout] running, jogging, heavy lifting, vigorous swimming, vigorous long-distance bicycling, strenuous manual labor) for at least 15 minutes [throughout]*

Moderate exercise: Medium intensity, but not exhausting (E.g., fast walking, tennis, easy bicycling, easy swimming, light lifting, moderate manual work) for at least 15 minutes [throughout]*

Mild/light exercise: Low amount of effort (E.g., yoga, archery, fishing, bowling, golf, easy walking, light manual work) for at least 15 minutes [throughout]*

What type of physical activity/exercise do you engage in regularly (include free time, work, chores, etc.)?

How Long Have You Been Exercising?*

Goal 1*

Goal 2*

Additional Goals

Goal 1*

Goal 2*

Additional Goals

Any other goal information you would like us to know about your goals

I've never been a person who sets clear goals.*

My friends support my interests and efforts.*

When physical activities get stressful, I stop them.*

I'm good at applying myself to new tasks.*

My family members support my interests and efforts.*

I can persist when a task is tiring, uncomfortable, and/or painful.*

I find it difficult using 'self-control' to keep myself successful.*

I don't like to overextend myself physically.*

I don't have people around who support my interests and efforts.*

If currently in a weight-loss program, please explain

How Long at Current Weight?*

Recent Weight Changes

How many daily portions of fruit do you average*

How many daily portions of vegetables do you average*

I affirm that the information I have provided is accurate to the best of my knowledge. I understand that this program involves voluntary participation in scheduled virtual appointments and is not a medical service. I agree to obtain medical clearance if I have any condition that may affect my ability to participate safely. *

I understand that throughout the program, I will complete short, validated, evidence-based surveys and inventories that assess key behavioral and psychological constructs—such as self-regulation for exercise, eating behaviors, mood, and emotional patterns. I acknowledge that these tools help track my progress, highlight areas where support may be most beneficial, and allow the program to be tailored to my needs.*

I understand that before beginning any new exercise program or intensifying an existing routine, it is recommended to consult with a qualified healthcare provider to ensure the activities are appropriate for my current health status. I acknowledge that the PAR-Q+ is an internationally recognized, evidence-based screening tool that helps identify any health considerations that may require medical guidance before starting or increasing physical activity. I agree to complete the PAR-Q+ using the link provided below.*

https://eparmedx.com/par-q/