INITIAL CONSULTATION QUESTIONNAIRE
All information shared on this document will be kept strictly confidential
PERSONAL INFORMATION
Name
*
First
Last
Gender
*
Birthdate
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Month
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Day
Year
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Location
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Street Address
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City
State / Province
Postal / Zip Code
Occupation
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Phone Number
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Email
*
Height
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Current Weight
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FITNESS & NUTRITION
Aimee Carpenter, NASM Certified Personal Trainer | Vanessa Mijares, Nutritionist
Which services are you interested in? (Check all that apply)
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Customized Workout/Fitness Plans (Aimee)
Customized Macronutrient "Macro" Breakdown Plans (Aimee or Vanessa)
Customized In-depth Nutrition and Meal Plans (Vanessa)
Other
What are your current health related goals? (Check all that apply)
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Weight Loss
Weight Gain
Body Recomposition
Increase Muscle Mass
Increase Strength
Improve Overall Health
Improve Flexibility
Stress Management
Other
How would you rate your current physical activity level?
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Please select
Little or no physical exercise
Occasional physical activity once or twice per week
Regular physical activity at least 3 times per week
Extremely active on a daily basis
Briefly describe your current exercise regimen (if applicable):
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How would you rate your current diet?
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Please select
Extremely healthy all of the time
Healthy most of the time during the week
It varies daily
Extremely unhealthy a majority or all of the time
Describe a typical day of meals (breakfast, lunch, dinner, and snacks)
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Do you have a desired timeline in which you would like to reach these goals?
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Please select
No
Less than 1 month
1-3 months
3-6 months
6-12 months
1 year or more
Additional comments:
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Please select a preferred date and time for your FREE 30 minute virtual consultation:
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