v2 – Physical Priming

🎨 Theme:

Section 1 of 10 Score: — Complete: 0%

⚠️ Please complete all required fields before submitting

Section 1: Demographics & Baseline

Basic information to establish client identity and context.

1.1 Full Name *

1.2 Date of Birth

📊 Age Reference: Under 50 = favorable | 50-65 = typical | Over 65 = modified approach

1.3 Email (for report) *

1.4 Referring Physician

Section 2: Body Composition

2.1 Weight (e.g., 85 kg or 187 lbs)

2.2 Height (e.g., 175 cm or 5’9″)

2.3 Waist Circumference

⚠️ Risk: Male >102cm | Female >88cm = high visceral fat

Section 3: T2D History & Severity

3.1 Date of Diagnosis (Month/Year) *

⏱️ <5 years = optimal reversal | 5-10 years = possible | >10 years = challenging

3.2 Most Recent A1c (%) *

📈 <6.5% Excellent | 6.5-7.4% Good | 7.5-8.4% Moderate | 8.5-9.4% High Risk | >9.5% Critical

3.3 Average Fasting Morning Glucose (mg/dL)

3.4 Are you currently taking INSULIN?

Yes No

3.4.1 Daily Insulin Units

3.4.2 Type of Insulin

3.5 Are you taking Sulfonylureas (glipizide, glyburide)?

Yes No

⚠️ Hypoglycemia risk during intervention – physician coordination required

Section 4: Complications & Comorbidities

4.1 Do you have neuropathy?

Yes No

4.1.1 Severity (1-10 scale)

4.2 Any history of heart disease or heart failure?

Yes No

🚩 Physician clearance mandatory before exercise program

4.3 eGFR (kidney function) if known

🚩 eGFR <45 = physician clearance required

Section 5: Lifestyle & Behaviors

5.1 Exercise sessions per week

5.2 Average sleep (hours/night)

5.3 Perceived stress (1-10)

5.4 Current diet pattern

Section 6: Psychology & Reversal Readiness

6.1 Commitment to reversal (1-10) *

6.2 Do you believe T2D can be reversed? *

Yes Unsure No

6.3 Has previous weight loss improved your blood sugar?

Yes (Strong predictor) No Never tried

6.4 What are you NOT willing to change?

Section 7: Family & Social Support

7.1 Family support level (1-10)

7.2 Parents or siblings with T2D?

7.3 Living situation

Section 8: Practical Logistics

8.1 Hours per week you can dedicate

8.2 Desired accountability level (1-5)

8.3 Ever done intermittent fasting?

Yes No

8.3.1 Longest fast completed (hours)

Section 9: Financial Commitment

9.1 Willing investment to become T2D-free ($)

9.2 Is cost a barrier?

Section 10: Physical Capability

10.1 Can you get up from chair without using arms?

10.2 Any joint pain limiting exercise?

📋 Assessment Results

📝 Consultant Notes (for internal record)

🔬 Armstrong Metabolic Reversal Assessment

Section 1: Demographics & Baseline

Section 2: Body Composition

Section 3: T2D History & Severity

Section 4: Complications & Comorbidities

Section 5: Lifestyle & Behaviors

Section 6: Psychology & Reversal Readiness

Section 7: Family & Social Support

Section 8: Practical Logistics

Section 9: Financial Commitment

Section 10: Physical Capability

📋 Assessment Results