FITNESS FORM
WWW.COOLBODYFITNESS.COM
Gender
Male
Female
Name
First Name
Last Name
Email
example@example.com
Height
Weight
What are your fitness goals?
Weight loss
Detox
Stress Management
Nutrition Advice
Energy Boost
Sports Enhancement
Bodybuilding
Fatloss
The following two questions: 1 - 10 (1=poor / 10=excellent)
How do you rate your current level of energy or vitality
How do you rate your current stress levels
How many hours sleep do you get a night?
Please list any supplements you are currently taking
Do you have any health complaint? Please describe.
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Do you exercise?
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
Please list the types of exercise you do regularly
Do you smoke?
Yes
No
How many per wk?
Do you take recreational drugs?
Yes
No
Please list any food allergies / intolerances that you are aware of?
How many glasses of water do you have a day?
Do you drink alcohol?
Yes
No
How many per week?
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Frequency of exercise (days per week):
6 - 7
3 - 5
1 - 2
0
Age >50 years:
No
Yes
Do you diet often?:
No
Yes
Planning to have a baby in the next 3-6 months:
No
Yes
Pregnant or breastfeeding:
No
Yes
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Choose one option that mostly applies to you
Which of the groups do you crave most?
sweets,breads and pasta
cheese, salty peanuts or chocolate
deep-fried foods or potato chips
ice cream, cream cheese. sour cream or milk
Do you
feel better on fruits and berries?
need coffee or stimulants to be awake?
experience a tight feeling over your right lower stomach area or rib cage?
experience constipation during menstration?
Do you have
to sleep with socks on at night because of feeling cold?
chronic inflammation in body?
headaches or head feels heavy in morning?
excessive menstrual bleeding?
Do you have
a weight problem more evenly distributed?
a hanging,sagging and loose abdomen?
a potruding abdomen (pot belly)?
excess fat on thighs, hips and a lower-stomach bulge?
Do you have
brittle nails with vertical ridges?
facial hair as a female?
pain or tightness in right-shoulder area?
pain in right or left lower back or hip area?
Do you have
a loss of hair on the outer third of the eyebrows?
dizziness when getting up too quickly?
hot or swollen feet?
menstrual cyclic brain fog?
Do you have
dry skin, especially hands and around elbows?
swollen ankles- socks leave creases on ankles?
flaky skin or dandruff in eyebrows and scalp?
menstrual cyclic hair loss?
Do you have
indentations on both sides of your tongue where the tongue meets the teeth?
shrinkage of the thigh muscles with difficulty getting up from a seated position?
dark yellow urine?
hot flashes?
Do you
have dry hair and hair loss?
wake up in the middle of the night (2 - 3 a.m)?
have a deep crevice ( deep crease appearance) down center of tongue and/or a white film on tongue?
have an upper body which is thinner than your lower body?
Do you have
puffiness around eyes?
an unusual feeling of being "out of breath" while climbing stairs?
skin problems (eczema, brown spots, psoriasis)?
low sex drive
Do you
become excessively tired in the early evening (7:30-8:00 p.m) and more awake in the early morning?
have a more active bladder at night than during the day?
have a yellow tint in the whites of your eyes?
have a history of ovarian or breast cysts?
Do you have
a lack of get-up-and-go (vitality)?
calcium issues or deposits- bursitis, tendontitis, kidney stones, heel spurs, early cataracts?
major moodiness if you skip a meal?
difficulty losing weight after pregnancy?
Do you have
a history of being on low calorie diets?
low tolerance for stressful situations, get easily irritable and on the edge?
stiffness and pain more in the right shoulder and right side of neck?
pain and tightness in one knee, worse during menstrual cycle?
Do you experience
not being able to maintain curls in your hair after using a curling iron?
cramps in the calves at night?
more itching at night?
water retention at certain times of the month?
Choose the one that mostly applies to you
Do you have excessive skin sagging under arms?
Do you have twitching under or on the top of left eyelid?
Are you not a morning person, yet feel more awake at night?
Do you have weight gain one week before menstrual period?
Are you
often depressed or feeling not so good?
a worrier or often anxious and nervous?
irritable, moody, grouchy in the morning?
moody/ irritable at certain times of the month?
Finish
Should be Empty: