Consulting Client Questionnaire

This questionnaire helps APP understand your goals, current habits, relevant health considerations, and preferences before an educational consulting session. This form is not a medical evaluation.

Consulting Scope and Important Disclaimer

Ageless Performance Project consulting provides general education, coaching, and informational support related to wellness, nutrition, physical activity, body composition, healthy aging, and performance. Richard Hare is participating solely as an APP consultant and is not acting as a chiropractor, physician, dietitian, mental health professional, or other treating healthcare provider.

No doctor-patient, chiropractor-patient, or other healthcare-provider relationship is created by completing this form, scheduling or participating in a consultation, purchasing a service, or communicating with APP. APP consulting does not include examination, diagnosis, treatment, prescribing, medical decision-making, or individualized medical care, and it is not a substitute for care from your own licensed healthcare professionals.

Do not start, stop, or change medication, supplements, diet, exercise, or medical treatment based solely on APP consulting. Discuss changes with the appropriately licensed clinician who knows your medical history. If you believe you may have an emergency, call 911 or seek immediate emergency care.

Client name

First Last

Preferred name

Date of birth

Email

Phone

Primary goals

What are your three highest priorities right now?

What would meaningful progress look like in 8 to 12 weeks?

What has made progress difficult in the past?

How ready do you feel to make changes? (1 = not ready; 5 = very ready)

How would you describe your current health? (Excellent, Good, Fair, Poor, or Prefer not to answer)

Medical conditions or diagnoses you want APP to know about

Condition, injury, symptom, or limitation affecting nutrition, exercise, weight management, or recovery

Who is currently involved in your care?

In the past 3 months, have you experienced chest pain, fainting, unexplained shortness of breath, rapid or irregular heartbeat, or symptoms that worsen with activity? (No, Yes, or Unsure)

Has a clinician advised you to avoid or limit exercise, weight loss, dietary changes, or specific activities? (No, Yes, or Unsure)

Are you pregnant, recently postpartum, or trying to become pregnant? (No, Yes, Not applicable, or Prefer not to answer)

Prescription medications you want considered, including weight-management or hormone-related medications

Nonprescription medications, vitamins, supplements, peptides, or performance products

Medication or food allergies, sensitivities, or adverse reactions

Health measurements or laboratory results you currently track

Do you have a prescribing clinician who monitors prescription weight-management or hormone therapy?

Height

Current weight and date measured (optional)

Dietary pattern, preferences, allergies, or intolerances

Untitled

Protein-rich servings usually eaten each day

Water or other nonalcoholic fluid usually consumed each day

Alcohol use

Significant weight changes, diets, medications, or programs you have tried and what happened

Current weekly exercise routine, including approximate duration and intensity

Pain, injury, balance concern, mobility limitation, or movement you currently avoid

Equipment and facilities available to you

Physical goals that matter most to you

Average sleep per night

How would you rate your sleep quality?

Have you been diagnosed with or screened for sleep apnea?

Current stress level

What most affects your recovery or consistency?

Typical workday and weekend schedule

Who or what supports your goals?

What format helps you most: simple action steps, detailed explanations, tracking tools, accountability, or a combination?

Financial, time, cultural, accessibility, or caregiving considerations that should shape your plan

Most important questions you want to discuss

Anything else you want APP to know

Client Attestation and Consent

By signing below, I confirm that the information I chose to provide is accurate to the best of my knowledge. I understand that APP consulting is educational and informational; it is not chiropractic care, medical care, diagnosis, treatment, or prescribing, and it does not establish a doctor-patient, chiropractor-patient, or other healthcare-provider relationship. I remain responsible for my decisions and for consulting appropriately licensed healthcare professionals about symptoms, diagnoses, medications, laboratory results, and treatment decisions.

I understand that I may decline to answer any question and may stop the consultation at any time.

Electronic signature — type your full legal name