Name
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First Name
Last Name
Email
*
example@example.com
Cell Phone
*
-
Area Code
Phone Number
Date of Birth
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-
Year
-
Month
Day
Date
Height & weight
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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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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List any medications you are currently taking.
Women only: are you in perimenopause or post-menopausal?
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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Are you a Clark County employee?
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
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 workouts do you do? How frequently? Are you working with a trainer?
Do you take any nutritional supplements? If so, what supplements?
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.
Macronutrient and Calorie Information
If you are currently tracking calories and macros, how long have you been tracking?
Thank you! If you are a Clark County Employee, you will receive an email from me regarding invoicing and scheduling.
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