The form itself is being hosted on an offline server. I’ll go ahead and provide the raw script in plain-text.
<p>Your Name
[text* your-name] </p>
<p>Your Email
[email* your-email] </p>
<p>Your Phone Number
[tel* your-tel “123-456-7890”] </p>
<p>Your Age
[text* your-age maxlength:2] </p>
<p>Subject
[text* your-subject] </p>
<p>Do You Work?
[checkbox* do-you-work “Yes” “no”] </p>
<p>Do you go to school?
[checkbox* do-you-go-to-school “Yes” “no”] </p>
<p>Do you take medication?
[checkbox* do-you-take-medication “Yes” “no”] </p>
<p>If yes, please list
[text if-yes-please-list] </p>
<p>Do you smoke?
[checkbox* do-you-smoke “Yes” “no”] </p>
<p>Do you suffer from any illness/allergies?
[checkbox* do-you-suffer-from-any-illness-allergy “Yes” “no”] </p>
<p>Do you have any joint pain?
[checkbox* join-pain “Yes” “no”] </p>
<p>Do you exercise?
[checkbox* do-you-exercise “Yes” “no”] </p>
<p>If yes, what type of exercise?
[text exercise-type] </p>
<p>How is your sleep?
[checkbox* how-is-your-sleep “Normal” “Anxiety(Waking between 1am – 4am)” “Insomnia”] </p>
<p>How many hours of sleep do you get?
[text* sleep-hours] </p>
<p>How is your mood?
[checkbox* your-mood “Calm” “Swings” “Angry”] </p>
<p>What is your energy level in the morning if 0=Low and 10=High?
[select* your-energy-am include_blank “0” “1” “2” “3” “4” “5” “6” “7” “8” “9” “10”] </p>
<p>What is your energy level after 4PM if 0=Low and 10=High?
[select* your-energy-pm include_blank “0” “1” “2” “3” “4” “5” “6” “7” “8” “9” “10”] </p>
<p>Do you suffer from anxiety, depression, or stress?
[checkbox* mental-health “Yes” “No”] </p>
<p>Do you take vitamins?
[checkbox* take-viatmins “Yes” “No”] </p>
<p>Do you take supplements?
[checkbox* take-supplements “Yes” “No”] </p>
<p>Do you drink coffee?
[checkbox* take-coffee “Yes” “No”] </p>
<p>If applicable, how is your menstruation/menopause?
[checkbox* your-menstruation “Pain” “Regular” “Heavy” “N/A”] <p/>
<p><b>Eating Habits</b></p>
<p>Breakfast
[textarea* breakfast-habits “What are your breakfast habits?”] </p>
<p>Lunch
[textarea* lunch-habits “What are your lunch habits?”] </p>
<p>Dinner
[textarea* dinner-habits “What are your dinner habits?”] </p>
<p>Beverages/Alcohol
[textarea* drinking-habits “What are your drinking habits?”] </p>
<p>Snacks
[textarea* snacking-habits “What are your snacking habits?”] </p>
<p>Do you have a history of diabetes, stroke, heart disease, cholesterol, high blood pressure, or other?
[textarea your-health] </p>
<p>Do you eat out?
[checkbox* eat-out “Yes” “No”] </p>
<p>If yes, cost?
[text out-cost] </p>
<p>How is your digestion?</ br>
[checkbox* your-digestion “Gas/Bloating” “Heartburn” “Sluggish” “Celiac” “Normal”] </p>
<p>How is your elimination?</ br>
[checkbox* your-elimination “Constipation” “IBS” “IBD” “Crohn’s” “Colitis” “Normal”]</p>
<p>What is your current body weight?
[text* body-weight] </p>
<p>What is your current body fat %?
[text* bodyfat-percentage] </p>
<p><b>Body Measurements</b></p>
<p>Chest
[text* chest-measure] </p>
<p>Waist
[text* waist-measure] </p>
<p>Hips
[text* hips-measure] </p>
<p>Arms
[text* arms-measure] </p>
<p>Thighs
[text* thighs-measure] </p>
<p>What are your goals?
[checkbox* your-goals “Weight Loss” “Weight Gain” “Energy” “Sleep” “Improve Digestion” free_text]
<p>[submit “Send”]</p>
