Welcome to The Longevity Lab

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Birthday (DD/MM/YYYY)*

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Preferred Method of Contact

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What Prompted You to Complete this Assessment Today?

Weight Loss / Body Composition

Improve Energy

Improve Sleep

Longevity & Healthy Aging

Stress Management

Athletic Performance

Recovery

Curiosity

Referral

Other

Which services are you interested in learning more about?

Supplement Strategy

Performance Nutrition

Brain Training

Biomarker Optimization

Personal Training

Recovery & Longevity Services

Not Sure Yet

Nutrition: (Please describe in detail)

Your average daily routine — meals, timing, habits, snacks, when you typically train + cardio etc:

Your vision for your physique — (lose fat, gain muscle, improve performance):

Any current medications including supplements. Remember, we will incorporate Supplement Strategy into your program:

Any food allergies or intolerances:

Whether you travel often or have upcoming events:

Foods you love or dislike:

The biggest challenges you face with aligning routine and nutrition:

Average alcohol consumption:

Whether you prefer a structured meal plan, macro tracking, or a mix of both:

Meal Prep Partnership:

I collaborate with Icon Meals, a local meal-prep company offering customizable meals (including breakfast options). WBFC clients receive 25% off, and meals can be shipped nationwide or picked up locally. Would you like to include Icon Meals in your plan?

Include Icon Meals

Yes

No

Unsure

Training & Recovery:

Current training and cardio regiment:

Current sleep habits:

Any injuries or limitations?

Are you currently or have you experienced working with a personal trainer in the past?

Vision & Goals:

What is Your Number #1 Goal RIght now?

Fat Loss

Muscle Gain

Energy Improvement

Performance Enhancement

Healthy Aging / Longevity

Improve Relationship with Food

Other:

If we were celebrating success six months from now, what would have changed?

Why is this goal important to you right now?

Stress & Lifestyle:

On a scale of 1-10, how would you rate your average stress level?

What creates the most stress in your life currently?

Do you feel your current stress level impacts your nutrition, recovery, or body composition?

Yes

No

Unsure

Recovery:

How many hours of sleep do you average each night?

How would you rate your sleep quality 1-10?

How is your energy throughout the day?

Excellent

Good

Average

Poor

When do you experience the biggest energy crash?

Supplements:

Have you ever worked with a personalized supplement protocol before?

Yes

No

Are you interested in receiving personalized supplement recommendations?

Yes

No

If no, what is your hesitation?

Biomarker:

Have you completed bloodwork within the last 12 months?

Yes

No

Would you be interested in reviewing your results with a Longevity Lab team member?

Yes

No

Environment:

Who is primarily responsible for food shopping and meal preparation in your household?

Do the people around you generally support your health goals?

Strongly Supportive

Somewhat Supportive

Neutral

Challenging Environment

Readiness:

On a scale of 1-10, how ready are you to make meaningful changes right now?

What would move that number one point higher?

Final Details:

What do you believe is the biggest obstacle standing between you and your goals? → Please share any additional factors that may affect your nutrition, metabolism, or ability to reach your goals.

If you could improve one thing immediately, what would it be?

You are Finished- Thank you! Once your assessment is received, a member of the Longevity Lab team will review your responses and contact you to discuss personalized recommendations and next steps.

Please fill out the form below.

Willow Bend Fitness Club

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