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Pre-Consult Questionnaire

Before you schedule your consultation with Phil Kaplan, please take some time and answer the following 10 questions candidly and thoroughly.  Reply to every question, even if the answer is "none" or "N/A."

All responses will be kept confidential. 

Your consultation and program selection will depend greatly upon your answers.

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Question 1 of 11

Please begin by typing your full name, the city & state you live in, and your current age (example: Phil Kaplan, Palm Beach FL, 60)

Question 2 of 11

Summarize, in a sentence or two, your primary health / fitness desire or concern (what would you most like to change?)

Question 3 of 11

Have you been diagnosed with any of the following?

(Select all that apply)
A

Heart Disease

B

Diabetes Type II

C

Diabetes Type I

D

Pre-Diabetes

E

Thyroid Condition

F

Metabolic Syndrome

G

Hypercholesterolemia (High Cholesterol)

H

Hypertension (High Blood Pressure)

I

Arthritis

J

Lyme Disease or Environmental Illness

K

Chronic Inflammatory Gut or Irritable Bowel Syndrome

L

I have not been diagnosed with any of the above

Question 4 of 11

Please share any relevant details related to your previous answer(s) and any chronic conditions you checked off as being concerns.

Question 5 of 11

Do you have any chronic or diagnosed conditions not mentioned prior?  If so, provide a brief description of the condition(s) and how it affects you.

Question 6 of 11

What are the most recent “solutions” you’ve tried in order to remedy your concerns or achieve your goals?

Question 7 of 11

Is Weight Loss (Fat Loss) a Concern?

A

Yes, I would like to lose 30 pounds or more

B

Yes, I would like to lose between 10 and 30 pounds

C

Yes, I'd like to lose up to 10 pounds

D

No, I'm OK with my weight but I want to lose some body fat

E

No, my present weight is pretty close to my ideal

Question 8 of 11

Describe, overall, how you generally feel.  Use any adjectives that apply (tired, energized, depressed, excited, etc.)

Question 9 of 11

This is a very subjective question, but it will help in determining which course or program is best for you.  On a general basis, how old do you feel?  Just answer with an age without detail or explanation.

Question 10 of 11

We're almost finished and this is an IMPORTANT one.  

Share just one element of “the ideal you.” In other words, if you can imagine a moment in the future when you feel “your best,” name one measure, or image, or sensation, or overall emotion, or event, or activity, or discussion . . . that will evidence “the program worked.”

Question 11 of 11

This is the last one.  Thanks for hanging in there and being transparent.  To wrap it up, add any comments you think are important or relevant. 

Confirm and Submit