Name
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First Name
Last Name
Email
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example@example.com
Cell Phone
*
-
Area Code
Phone Number
Date of Birth
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-
Year
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Month
Day
Date
Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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-
Area Code
Phone Number
Health & Fitness Goals
What goals do you hope to accomplish?
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Fat Loss
Increased Strength
Increased Muscle Mass
Weight Gain
Better Digestion
More Energy
Better Sleep
Other
Out of all of these goals, which is the most important to you?
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Do you have a specific timeline for achieving that goal? If so, please specify:
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What do you see being the biggest challenges for you to accomplish your goal?
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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)?
Medical and Health Information
Do you have any diagnosed health problems, list condition(s). (Diabetes, heart disease, high blood pressure, hypothyroidism, etc)
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Do you have any physical limitations? (asthma, bad knees, back, wrists, etc)
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List any medications you are currently taking.
Any additional health information you would like to share? (Hereditary diseases, hunches on potential issues, food allergies)
Lifestyle Information
What do you do for a living/occupation?
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How would you best describe your activity level during the day?
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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
Does your work involve shift work?
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Yes
No
Describe your work schedule, hours worked, time of day, days per week.
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Do you travel for work, if so how much?
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Tell us a bit about your family, if you have one, and weekly activities that you do with them?
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When do you typically go to bed?
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1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
When do you typically wake up?
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1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Describe your wake up routine. Do you need an alarm clock? Do you pop out of bed right away? Basically is waking up hard and how rested do you feel?
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Who does the grocery shopping in your house? Who does the cooking? Do you have any meal prep routines?
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Fitness, Diet and Nutrition Information
Explain your fitness/exercise routine? What kinds of workokuts do you do? How frequently? Are you working with a trainer?
Do you take any nutritional supplements? If so, what supplements and what dosage?
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How many times a week do you eat out at restaurants?
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Do you follow any dietary guidelines? Vegan, Paleo, Pescatarian, etc? Also explain if you have any known food intolerances or foods you avoid.
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Macronutrient and Calorie Information
If you are currently tracking calories and macros, how long have you been tracking?
If you are currently tracking and in a calorie deficit, how long have you been eating in a deficit?
Relationships
Are you married or in a relationship with someone?
Yes
No
Other
Are they supportive of your desire to get healthy??
Thank you for taking the time to fill out this form and let us know more about you. If there is anything else you would like to let us know about concerning your diet, health, fitness, family, routines, work or whatever please do so below.
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