Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Medical and Health Information
What is your height (cms), weight (kgs), and bodyfat % (if known)?
Are you familiar with tracking your macronutrient or calorie intake?
*
Select...
Yes
No
Calories only
What is your current macronutrient intake? Please list the number of grams of protein, carbohydrates, and fats.
*
How long have you been at this intake?
*
Have you been gaining, maintaining, or losing weight at this intake?
*
Gaining weight
Maintaining weight
Losing weight
Please provide links to images of your physique
Please list any diet history
Do you have any diagnosed health problems, list condition(s). (Diabetes, heart disease, high blood pressure, hypothyroidism, etc)
*
List any medications you are currently taking.
Do you have any physical limitations? (asthma, bad knees, back, wrists, etc)
*
Any additional health information you would like to share? (Hereditary diseases, hunches on potential issues, food allergies)
Health & Fitness Goals
What are your short term goals?
*
Fat Loss
Increased Strength
Increased Muscle Mass
Weight Gain
Better Digestion
More Energy
Better Sleep
Other
What your key drivers are for achieving these short term goals?
*
What are your long term goals?
*
Fat Loss
Increased Strength
Increased Muscle Mass
Weight Gain
Better Digestion
More Energy
Better Sleep
Other
What your key drivers are for achieving these long term goals?
*
Do you have a specific timeline for achieving that goal? If so, please specify:
*
What do you see being the biggest challenges for you to accomplish your goal?
*
Consistent Exercise
Diet
Time Management
Meal Planning
Checking in with us
Support from family, friend, coworkers
Staying focused on weekends
Nothing, I'm ready to go
Other
Is there anything else you would like to tell us about your health and fitness goal(s)?
Lifestyle Information
How would you best describe your activity level during the day?
*
None, sedentary job, little activity at home
Moderate, light activity during the day and at home
Active, on your feet most of the day but nothing strenous
Heavy, on your feet and doing strenuous activity throughout the day
How many hours of sleep do you get a night?
less than 5
5 to 8
8 to 12
more than 12
How would you rate your current stress levels?
1 (low)
2
3
4
5 (high)
Diet and Nutrition Information
What would you rate your nutritional literacy?
1 (poor)
2
3
4
5 (excellent)
Do you take any nutritional supplements? If so, what supplements and what dosage?
*
Do you follow any dietary guidelines? Vegan, Paleo, Pescatarian, etc? Also explain if you have any known food intolerances or foods you avoid.
*
What are your expectations of having a training/nutrition coach?
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