General Information and Daily Activity Level

General Information and Daily Activity Level

This is to determine the caloric needs per day based on your activity level, gender, age, current weight, and goals. Reviewing this information is important to ensure that you are given the correct and safe programs for your needs. Answer the following questions to the best of your ability and reach out if you have any questions. It may seem like a lot of information at once, but having you do this now prevents us from doing this in your consultation. The more accurate the information the better results you can expect to have.
Name*

First NameLast Name
Email
example@example.com
The birthdate is for age purposes only, which will have an impact on many aspects of health and creating a safe program. If you would rather just include your age, that is fine. However, I will not know when we need to celebrate your birthday!
Birthdate

MonthDayYear
Date
Age
Gender*

MaleFemaleN/A
Occupation*
Hours typically spent working per week?
JOB ACTIVITY DESCRIPTIONS

Sedentary: office job (sitting, studying, little walking)

Light: any job where you mostly stand or walk (teacher, waitress)

Moderate: job requires physical activity (landscaper)

Heavy: Heavy manual labor (construction/athlete)

Very Heavy: Moderate or heavy minimum of 8 hours
How active is your job/typical day?*
Use the JOB ACTIVITY DESCRIPTIONS to answer correctly.
Typical step count per day.*
If you do not have a tracker for steps, please take an educated guess.
How frequently do you exercise per week?*
WORKOUT INTENSITY SCALE

1-minimum effort

2-light and easy

3-comfortable pace

4-comfortable with some effort

5-progressive pace

6- hard activity

7-vigorous activity

8- hard intensity

9-very hard intensity

10- all out sprint
On a scale of 1-10, how would you describe your typical workouts? (Use the descriptions to choose the correct response.)*
USE WORKOUT INTENSITY SCALE to answer correctly.
YesNo
If yes, what range is your heartrate typically at when exercising?
EX: 120-130 bpm
If you currently exercise, what kind of exercises do you perform typically? (check all that apply)

WalkingJogging/runningCyclingStrength trainingHIIT (High-intensity interval training)Yoga/Pilates/stretchingAt home workout programs (ex; Beachbody, Les Mills)CrossfitDance (aerobics/zumba)Other
YesNo
If no, please explain why and which exercises.
Are you currently dealing with any injuries or pain in your daily tasks?
Ex: pain in knees while walking, unable to kneel, unable to reach in the high cabinets in the kitchen
Have you had an injury in the past or present, that inhibits any types of movements?
Ex: Rotator cuff injury, knee bursitis. ACL injury, neck or spinal injuries
Have you had any surgeries that would still impact your exercising and movement patterns?
Ex: knee surgeries, rotator cuff surgery, neck or spinal injuries
Typically how many hours of sleep do you get a night?*
Height*
Feet and inches
What is your current weight?*
Do you have any of the following health issues?

Type 1 DiabetesType 2 DiabetesHigh blood pressure (hypertension)Low blood pressure (hypotension)DepressionAnxietyHeart diseaseKidney diseaseLiver disease (Hep A, B, C)High cholesterolOsteoperosis/osteopeniaOther
If you answered other above, please explain.
YesNo
If yes to previous question, please explain
Currently smokeHave never smokedPrevious smoker
IF you currently smoke, how much how often? IF you are a previous smoker, how long ago did you quit?
Ex: Smoke a pack a day; Quit 5 years ago
What are your top 3 goals and the reason you are focusing on improving your health?*
Have you thought about your "why" to these goals or how it will make you feel when you reach your goals? Explain a little if you would like?
Ex: My why is to be able to keep up with my children. I will feel confident once I fit back into my pre-pregnancy clothes.
What are you willing to do to reach your goal? (check all that apply)

Commit to an exercise program (typically 3-5 sessions a week)Eat mostly whole foods and reduce processed foodsMostly eat at home and reduce eating outAccurately provide me with how you are following the plan(s)
Are any medications that you are currently taking, going to impact you while exercising? If yes please explain.
IF YOU ARE UNSURE, PLEASE LIST MEDICATION
Has a doctor recently suggested that you focus on your health and start a workout regimen? What exactly did they suggest to optimize your health?
Is there anything that needs to be brought to my attention before writing you an exercise program?
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