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DexaFit Tampa Registration Form
You have selected the Body Composition Assessment with DEXA service. This screening is performed using a low dose x-ray and requires a medical clearance questionnaire.
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1
Personal and Contact Info
First Name
Last Name
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Please enter your phone
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Female
Male
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Female
Male
Gender
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American Indian or Alaska Native. ...
Asian. ...
Black or African American. ...
Hispanic or Latino. ...
Native Hawaiian or Other Pacific Islander. ...
White
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Please Select
American Indian or Alaska Native. ...
Asian. ...
Black or African American. ...
Hispanic or Latino. ...
Native Hawaiian or Other Pacific Islander. ...
White
Ethnicity
How tall are you in inches (60 in = 5 ft | 72 in = 6 ft)
How much do you weigh? (in lbs)
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2
What can we help you with today?
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We use diagnostic and laboratory testing of your body composition, cardiovascular system, food intolerances, hormones, and other key biometrics to help you achieve an optimal state of health. Check all that apply.
My body composition health (DEXA and 3D body scan)
My cardiovascular health (Vo2max)
My metabolic health (RMR)
My food intolerances
My biomarkers (hormones, blood sugar, minerals, etc)
My DNA
My microbiome
Other
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3
What are your specific physical performance goals?
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Overall health and longevity
Strength and power training
Cardiovascular endurance sports (Running, Cycling)
Not sure
Other
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4
Is there a chance you are pregnant?
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Females Only
YES
NO
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5
What is your birth date?
Please note, if you're on your mobile device, tap the 'year' in order to change it.
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Date
Year
Month
Day
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6
Do you have
any kind of condition that will prevent you from laying still
on the scanning table for roughly 6 minutes?
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YES
NO
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7
Has a doctor ever said you have a heart condition?
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YES
NO
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8
Do you feel pain in your chest when you do physical activity?
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YES
NO
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9
Do you lose your balance because of dizziness or do you ever lose consciousness?
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YES
NO
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10
Are you currently taking any prescription drugs for blood pressure or any other heart condition?
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YES
NO
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11
Do you have any bone or joint problem that could be made worse by physical activity?
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YES
NO
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12
Is this your first visit to DexaFit?
Yes, this is my first time
No, this is a follow-up visit
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13
Is there a
history of heart disease
in your family?
Yes, on my Mother's side
Yes, on my Father's side
Yes, on both sides of my family
No
Not sure
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Is there a
history of obesity
in your family?
Yes, on my Mother's side
Yes, on my Father's side
Yes, on both sides of my family
No
Not sure
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Is there a
history of osteoporosis or low bone density
in your family?
Yes, on my Mother's side
Yes, on my Father's side
Yes, on both sides of my family
No
Not sure
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16
Is there a
history of diabetes
in your family?
Yes, on my Mother's side
Yes, on my Father's side
Yes, on both sides of my family
No
Not sure
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17
What best describes you when it comes to your fitness habits and goals?
Couch Potato
Weekend Warrior
Fitness Driven/"Biohacker"
Elite Athlete
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18
How often do you smoke?
*Nicotine-based products
Never
Rarely
Sometimes
Daily
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19
How often do you drink alcohol?
Never
Rarely
Sometimes
Daily
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20
How often do you meditate?
Never
Rarely
Sometimes
Daily
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21
How much time do you spend outside on weekdays?
Less than 10 minutes
10-30 minutes
30-60 minutes
1-2 hours
2+ hours
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22
Do you have any food sensitivities?
Yes, severely
Yes, somewhat
Not sure
No
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23
Do you try to avoid consuming fluoride in products?
Water you drink, toothpaste, etc
YES
NO
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24
How do you describe your diet?
I eat everything
Gluten-free
Vegetarian
Pescetarian
Raw
Intermittent Fasting
Dairy-free
Paleo
Low-Carb
Keto
Bulletproof
Epi-paleo
Other
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25
How often do you exercise/workout?
1-2 times per week
3-4 times per week
4-6 times per week
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26
How long can you jog without stopping?
I'm lucky to make it 10 to 12 minutes
About 15 minutes
More than 30 minutes
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27
What kind of exercise(s) do you like?
Check all that apply
Soccer
Hiking
Martial Arts
Dance
Running
Biking
Gymnastics
Baseball
Walking
Basketball
Volleyball
Yoga
ARX
Tennis
Rowing
Aerobics
Ice Skating
Pilates
CrossFit
Weight Training
Other
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28
How many hours do you sleep per night on average?
4 or less
5 to 6 hours
7 to 8 hours
9 to 10 hours
11+ hours
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29
Describe your sleep this past week?
Excellent
Good
Average
Poor
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30
How much sunlight do you get each morning?
I don't know. I don't think about getting any.
I'm outside every morning for at least 10 to 20 minutes.
I try to get more than 20 minutes every morning.
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31
How many hours do you spend in front of a screen every day?
Computer/tablet/TV/phone
Less than 1 hour
2 to 4 hours
4 to 6 hours
7+ hours
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32
Do you experience any of these sleep issues?
Choose as many as you like.
Trouble falling asleep
Waking up frequently
Difficulty going back to sleep after waking up
Snoring
Sleep Apnea
Nightmare/bad dreams
Still tired after waking up
Cramps
Night sweats
Other
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33
What do you do to help yourself fall asleep?
Choose as many as you like.
Wear blue blocking glasses to mitigate blue light at night
Magnesium supplement
Melatonin supplement
Herbal tea (for sleep)
Avoid eating too close to bedtime
Prescription sleep medication
Meditate
Read
Hot shower
Cold shower
Other
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34
Are you taking any medications or supplements, currently?
Yes
No
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35
If yes, please list them here
Please list all medications and supplements that you are currently taking. If more than one, please separate them with a comma.
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36
What brought you to DexaFit?
Use the space below to tell us more about yourself, your goals, and any questions you have.
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37
*
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USER AGREEMENT, CONSENT TO TELEMEDICINE, AND AUTHORIZATION FOR USE OF MY INFORMATION BY DEXAFIT
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