By completing this questionnaire, you consent to Orena Health Inc. collecting and using your health information to provide personalized wellness recommendations, exercise plan and follow-up services. This questionnaire is intended for health screening and wellness purposes and does not provide a medical diagnosis or replace advice from a qualified healthcare professional.

Your Name:

Your Email (Used to Return your Meal & Exercise plan ):

Your Occupation:

Your Address:

Questions for Exercise Plan

Select your Fitness Goals:
NoneLose Body FatWeight LossWeight GainMaintain Current WeightImprove My Body's PhysiqueImprove HealthBuild muscleTo Gain StrengthStress ReliefRehabilitation (Recover from Illness)Managing DiseaseImprove Athletic PerformanceIncrease stamina and EndureIncrease Daily Energy Levels

State Other Fitness Goals:

How would you describe your daily activity level?
NoneSedentary (little to no moving around, work a desk)Light Active (light exercise 1-3 days per week)Moderately Active (moderate 3-5 days of exercise)Very active (6-7days)Extremely active

How Often Do you Exercise?
Multiple Times DailyOnce Daily5+ days/week3–4 days/Week1–2 days/WeekOnce a MonthNever

What type of exercise do you usually do?
Free WeightsFixed ResistanceCardio (Running, Walking Treadmill, Bike, etc.)Group Classes (Spin, Zumba, etc.)Holistic (Yoga, Mobility, Pilate etc.)None

Your Target Weight:

Daily Activity Level (Outside of the gym):
NoneSedentary (Desk job, very little movement)Lightly Active (Desk job but I walk around occasionally)Moderately Active (On my feet a lot, e.g., retail, nursing, teaching)Very Active (Physical labor job, e.g., construction, landscaping)

Do you have any current or past injuries? If yes, please describe location and severity:

Do you have any Immobilities? If yes, list them:

Are there exercises or activities you like and want to do:

Are there exercises or activities you dislike or want to avoid:

How much time can you spend per exercise session?

Medical Questions

Medical Conditions Affecting Diet (Check all that apply):
NoneType 1 or Type 2 DiabetesHigh Blood Pressure/HypertensionHigh CholesterolIBS / Digestive Issues (Bloating, gas, etc.)Acid Reflux / GERDPCOS (Polycystic Ovary Syndrome)Thyroid ConditionKidney DiseaseGastrointestinal DiseaseCardiovascular Diseases

List any other Medical Conditions:

Are you on any medications?

Current Supplements:
Creatine MonohydratePre-Workout / CaffeineFish Oil / Omega-3sMultivitaminVitamin AVitamin BVitamin CVitamin DIronMagnesiumZincBCAAs / EAAsProtein powersHerbal supplementsNone

Would you be willing to Review this Nutrition and Fitness Service:
YESNO

I consent to submitting my medical data strictly to generate my meal plan:
YES