Intake Survey - Cordova Health Collective

Are you a current or past patient of this clinic?

Current patient (I see my provider on a regular basis)

Past patient (it has been more than 6 months since an appointment)

Never been a patient

What do you hope to gain from this interpretation?

Confirm that I'm on the right track with my health

Understand potential root causes of my symptoms

Take proactive steps to prevent future health issues based on my risks and family history

Optimize my overall health and well-being

Other

What is your height?

Please enter your height in feet and inches.

Feet(Required)

Inches(Required)

What is your weight?

Please enter your weight in pounds.

Weight (lbs)(Required)

What is your current smoking status?

I do not smoke

I am a current smoker

I used to smoke, but have since quit

What types of physical activity do you enjoy?

Cardio & Endurance (running, cycling, swimming, HIIT)

Strength & Resistance Training (weightlifting, bodyweight exercises, resistance bands)

Low Impact (yoga, Pilates, tai chi)

Outdoor activities (hiking, kayaking, rock climbing)

Sports (tennis, basketball, soccer, etc)

Dance (Zumba, ballet, salsa, etc)

Everyday Movement (walking, housework, active commuting)

Other

None

How many days a week are you doing 30+ mins of strenuous physical activity?

1-2 days

3-5 days

5-7 days

None

What best describes your typical weekday?

Mostly sedentary (desk job, remote work, minimal movement)

Moderately active (mix of sitting and movement throughout the day)

Physically active (on my feet most of the day, some manual labor)

Highly active (physically demanding job, heavy lifting, constant movement)

Are you currently taking any supplements?

Yes

Have you ever had any surgeries?

Yes

Please specify...(Required)

Are you a current or past patient of this clinic?

Current patient (I see my provider on a regular basis)

Past patient (it has been more than 6 months since an appointment)

Never been a patient

What do you hope to gain from this interpretation?

Confirm that I'm on the right track with my health

Understand potential root causes of my symptoms

Take proactive steps to prevent future health issues based on my risks and family history

Optimize my overall health and well-being

Other

What is your height?

Please enter your height in feet and inches.

Feet(Required)

Inches(Required)

What is your weight?

Please enter your weight in pounds.

Weight (lbs)(Required)

What is your current smoking status?

I do not smoke

I am a current smoker

I used to smoke, but have since quit

What types of physical activity do you enjoy?

Cardio & Endurance (running, cycling, swimming, HIIT)

Strength & Resistance Training (weightlifting, bodyweight exercises, resistance bands)

Low Impact (yoga, Pilates, tai chi)

Outdoor activities (hiking, kayaking, rock climbing)

Sports (tennis, basketball, soccer, etc)

Dance (Zumba, ballet, salsa, etc)

Everyday Movement (walking, housework, active commuting)

Other

None

How many days a week are you doing 30+ mins of strenuous physical activity?

1-2 days

3-5 days

5-7 days

None

What best describes your typical weekday?

Mostly sedentary (desk job, remote work, minimal movement)

Moderately active (mix of sitting and movement throughout the day)

Physically active (on my feet most of the day, some manual labor)

Highly active (physically demanding job, heavy lifting, constant movement)

Are you currently taking any supplements?

Yes

Have you ever had any surgeries?

Yes

Please specify...(Required)

What is your height?

What is your weight?

What is your height?

What is your weight?

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