First Name *

Last Name *

E-mail *

Address *

City *

State *

Zip Code *

Gender *

Age *

Height *

Weight(lbs) *

Home Phone *

Cell Phone *


Please tell us how you heard about Kasper Institute and/or this assessment. Who were you referred by? *

What are your primary health concerns? *

What are your concerns, if any, about body weight? *

Have you ever been on a diet? *

If Yes, which one(s):

How high is your stress level? *

Where is your stress from, how does it affect you? *

What are your eating habits? (How many meals, size of meals, what do you typically eat?) *

Do you have any other health/heart concerns? *

If Yes, what are they?

Do you take vitamins or supplements? *

If Yes, where do you get your vitamins from?

Are you on any medications? *

If Yes to vitamins, supplements or medications, what are you taking?

What are your health/training goals? What do you want your health to be? What do you want your body to look like? *

Do you have difficulty sleeping? *

Do you have sugar or salt cravings? *

Do you have pain in your lower back, shoulders, hips, ankles on a daily basis? *

Are you exhausted at the beginning or end of your day? *

Do you normally feel depressed or angry on a daily basis? *