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           VITA — Pre-Session Health Questionnaire
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Hi there,

I'm VITA, your health and longevity coach. Thank you for booking your
free coaching session — I'm looking forward to working with you.

Before we meet, I'd like to learn a little about you and your health.
This questionnaire takes about 5 minutes to complete. Your answers help
me prepare a session that's tailored specifically to you — not generic
advice you could find anywhere online.

Everything you share is kept strictly confidential.

Please fill this out and return it at least 24 hours before your session.

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SECTION 1 — ABOUT YOU
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Full name:

Email address:

Phone number:

Age:

Gender:


SECTION 2 — YOUR HEALTH GOALS
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1. What are the 3 biggest health goals you have right now?
   (Examples: better sleep, more energy, lose weight, slow aging,
   reduce stress, sharpen brain, build muscle, fix gut health)

   Goal 1:

   Goal 2:

   Goal 3:


2. What do you believe has been the biggest obstacle to achieving
   these health goals?




3. If you could fix ONE thing about your health in the next 3 months
   — guaranteed — what would it be?




SECTION 3 — YOUR CURRENT HEALTH
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4. Are you currently taking any supplements?
   If yes, please list them (name and dosage if you know it):




5. Are you currently on any medications?
   (I need to know this so I can avoid recommending anything that
   could cause interactions. This stays completely confidential.)




6. How would you rate your SLEEP quality?

   [ ] 1 — Terrible. I dread bedtime.
   [ ] 2 — Poor. I rarely wake up feeling rested.
   [ ] 3 — Average. Some good nights, some bad.
   [ ] 4 — Good. I sleep well most nights.
   [ ] 5 — Excellent. I fall asleep fast and wake up refreshed.


7. How would you rate your ENERGY levels throughout the day?

   [ ] 1 — Exhausted. I run on caffeine and willpower.
   [ ] 2 — Low. I hit a wall most afternoons.
   [ ] 3 — Average. Enough to get through the day.
   [ ] 4 — Good. I feel energised most of the time.
   [ ] 5 — Excellent. Steady energy from morning to night.


8. How would you rate your STRESS levels?

   [ ] 1 — Minimal. Life feels manageable.
   [ ] 2 — Mild. Occasional stress but I handle it well.
   [ ] 3 — Moderate. Stress is a regular part of my life.
   [ ] 4 — High. I feel overwhelmed more often than not.
   [ ] 5 — Severe. Stress is affecting my health and daily life.


9. Do you have any known allergies or medical conditions?
   (e.g., thyroid issues, diabetes, autoimmune conditions, food
   allergies, heart conditions — anything relevant)




SECTION 4 — ONE LAST THING
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10. How did you hear about VITA?

    [ ] Social media
    [ ] Google search
    [ ] Friend or family referral
    [ ] Longevity Futures website
    [ ] Other: _______________


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That's it. Thank you for taking the time to fill this out — it makes
a real difference.

I'll review your answers before our session so we can hit the ground
running. No wasted time, no generic advice. Just a plan built for you.

See you soon.

— VITA
   Health & Longevity Coach
   Longevity Futures

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