Chalk | Peak Performance Profile Analysis

1
What is your age group?* This field is required.
18-24
25-34
35-44
45-54
55-64
65+
2
When is your birthday?* This field is required.
Month
Day
Year
3
How would you describe your current level of physical activity?* This field is required.
Sedentary (little or no exercise)
Lightly active (light exercise/sports 1-3 days/week)
Moderately active (moderate exercise/sports 3-5 days/week)
Very active (hard exercise/sports 6-7 days a week)
Extra active (very hard exercise & physical job)
4
On average, how many glasses of water do you drink each day?* This field is required.
Less than 4 glasses
4-8 glasses
More than 8 glasses
5
How many hours of sleep do you typically get each night?* This field is required.
Less than 5 hours
5-6 hours
7-8 hours
More than 8 hours
6
How often do you engage in strength training exercises each week?* This field is required.
None
1-2 times
3-4 times
5+ times
7
How many days per week do you usually do cardiovascular exercises?* This field is required.
None
1-2 times
3-4 times
5+ times
8
How would you describe your typical eating habits?* This field is required.
Mostly fast food/processed foods
A mix of healthy and unhealthy foods
Mostly fresh, whole foods
9
How would you rate your stress levels on an average day?* This field is required.
Very high stress
Moderate stress
Low stress
10
How often do you perform mobility or flexibility workouts each week?* This field is required.
None
1-2 times
3+ times
11
How would you rate your overall health status?* This field is required.
Poor
Fair
Good
Excellent
12
What’s your biggest fitness goal in the next 90 days?* This field is required.
Lose fat
Build muscle
Get toned
13
What is your height?* This field is required.
Under 4'
4'0" - 5'0"
5'1" - 5'8"
5'9" - 6'0"
6'1" - 6'4"
6'5" +
14
What is your current weight?* This field is required.
Under 100 lbs
100 - 125 lbs
126 - 150 lbs
151 - 180 lbs
181 - 200 lbs
201 - 230 lbs
231 - 250 lbs
251 - 300 lbs
300 lbs +
15
What’s usually harder for you?* This field is required.
Sticking to a diet plan
Consistently working out
Avoiding unhealthy snacking or emotional eating
Getting adequate rest and recovery
16
How many much weight you want to lose in the next 90 days (if any)?* This field is required.
I'm not looking to lose weight
1-10 Pounds / 1-5 Kilograms
11-20 Pounds / 5-10 Kilograms
21-30 Pounds / 11-15 Kilograms
31-40 Pounds / 16-20 Kilograms
41+ Pounds / 21+ Kilograms
17
What’s your BIGGEST motivation for getting in shape?* This field is required.
I want to look more attractive to others
I want to feel more confident in my own skin
I want to look amazing for an upcoming vacation/wedding/special event
I want to be healthier
I want to like what I see in the mirror
18
Could you please share your monthly household income range in USD? This information helps us better understand how to guide you with exclusive fitness and nutritional recommendations.* This field is required.
Less than $2,000 per month
$2,001 - $3,000 per month
$3,001 - $5,000 per month
$5,001 - $8,000 per month
$8,001 - $10,000 per month
$10,001 - $20,000 per month
More than $20,000 per month
19
Would you be open to investing in our exclusive Chalk Performance VIP Program, designed to help you achieve your fitness goals within 90 days, with a guarantee of results or a full refund?* This field is required.
Yes, I can invest if there's a fit during the call.
No, I cannot invest right now.
20
Please share if you have any of the following conditions. This will help us determine if we are qualified to help you at this time (check all that apply. Your information will be confidential):* This field is required.
High Blood Pressure (untreated)
Asthma (severe)
COPD
Parkinson’s Disease
Dementia/Alzheimer’s
Motor Neuron Disease
Metabolic Myopathies
Chronic Obstructive Pulmonary Disease
Chronic Kidney Disease
Systemic Lupus
Cystic Fibrosis
Open Heart Surgery (post-op)
Torn Ligaments/Tendons/Tissues
Uncontrolled Tachycardia
Late Stage MS or other neuromuscular degenerative diseases
Spinal Stenosis
Schizophrenia
Undergoing Chemotherapy/Radiation
None of the Above
21
Please type in your FIRST name below:* This field is required.
22
Please type in your FIRST name below - Formatted* This field is required.
23
Please type in your LAST name below:* This field is required.
24
What's your gender* This field is required.
Male
Female
25
Hey {firstname}! Nice to meet you. What's your email?* This field is required.
26
Last question: what's your mobile phone number?* This field is required.
27
This is your final step for submitting your Peak Performance Profile Analysis. By checking this box, you are providing express written consent to receive email, voice and SMS communication from Chalk about your results. You have the right to revoke this consent at any time. To do so, please click the unsubscribe link in our emails, reply ‘STOP’ to any text message you receive from us. You also acknowledge you are not required to provide this consent as a condition of purchasing any goods or services from Chalk.* This field is required.Privacy policy Terms and conditions
Yes, I acknowledge and confirm the terms and conditions above.
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Today's Date
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Today's date + 90 days
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Peak Performance Profile Score
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Peak Performance Types
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Income Tier
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utm_term
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utm_source
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utm_campaign
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Hidden Box
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User Agent String
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Get Page URL
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1. Emerging Enthusiast
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2. Fitness Focused
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3. Peak Performer
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