Initial Intake Form

Full Legal Name *

Height *

Current Weight *

Date of Birth (MM-DD-YYYY) *

At what age did you feel your best? *

Address *

City *

State *

Postal code *

Country *

Gender *

Male

Female

Email *

Phone *

Which event? *

Who referred you? *

Which podcast? *

Please specify: *

What aspects of Gladden Longevity are you interested in? (check all that apply) *

Personalized Health Program

Podcast - become an Age Hacker

GL Store - Proprietary + Curated Supplements

Book - “100 is the New 30”

What is your timeline for starting a personalized health program?

I’m ready to start now, as soon as possible

I’d like to begin my program in a month

I’d like to start in 2-3 months

I’m interested in a program that would start in > 3 months

(Answer only if you selected "Personalized Health Program" in your previous question, else you may skip this question.)

Health

What are your top 3 pain points? *

What are your top 3 health goals? *

What do you perceive are your greatest hurdles in achieving your health goals? *

Do you have any medical conditions or health concerns you’d like to share? *

Commitment

Are you able to visit the Gladden Longevity Clinic and Advanced Performance Center in Dallas TX for an in-person assessment? *

Yes, I can visit Dallas TX for a minimum of 2 days

No, I’m only interested in virtual support

The personalized health programs at Gladden Longevity start with a minimum investment of $25K. Please indicate whether this fits within your current budget. *

Yes

Success

We’ve found that understanding your personal motivations is a key component of client success. What fuels your desire to optimize your health and Live Young for a Lifetime? (Checkbox) *

Unlock the secrets to a longer, vibrant life

Supercharge your energy for epic playtime with your kids/grandkids

Stress-proof your days and reclaim your inner peace

Amp up your physical appearance and feel confident in your own skin

Proactively prevent or manage specific health conditions

Turbocharge your mental clarity and focus for peak performance

Enhance your overall well-being to live your best life

Other (please share your unique motivation)

If Other (please share your unique motivation)

What does your vision of success look and feel like after partnering with Gladden Longevity? *

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