Basics
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
What is your overall fitness goal? Weight/fat loss, muscle gain, body recomposition, cardiovascular endurance, other?
Height
Inches
Weight
Lbs
Current Waist Measurement: Measure at small of the waist or belly button and please note for consistency in future measurement.
Current Hips Measurement: Stand to the side and find the biggest point or the "peak" of circumference.
Are you passionate about your goals? How hungry and important are your goals? On a scale from 1 - 10, please indicate importance.
Please attach three initial photos; front, side and back. See sample photos below, or take them now.
Browse Files
Cancel
of
Take Photo Front
Take Photo Side
Take Photo Back
Back
Next
Save
Workouts
Current workout schedule: It's ok if you don't currently have one
What do you enjoy doing for physical activity?
Have you engaged in a workout program that has been effective for you?
Lifestyle
Do you have a fitness tracker (Like a fitbit?) If so, on average, how many steps do you do daily?
How do you spend the majority of your day? (Example: sedentary office worker, teacher, stay at home mom, etc.)
How many hours of sleep do you get a night?
How many hours of work do you do a week?
What is your daily stress on a level of 1 - 10?
What are your current hobbies/interests?
Back
Next
Save
Diet
Current Calories/Macros:
How long have you been following those and to what consistency?
Do you use a log such as My Fitness Pal (MFP)?
What rate have you been gaining or losing?
Recent and long-term dieting history?
Do you eat out at restraurants/fast food? How often?
Do you drink alcohol? Frequency and how much?
Do you have to consume alcohol in your plan?
What creates your desire for poor food choices? Binging, etc.
Current Supplements? Please include all vitamins, protein supplements, workout products such as BCAA's, etc.
Do you have any food allergies or dietary restrictions?
Back
Next
Save
OTHER PERTINENT INFORMATION
When was your last up to date physical?
When was your last endocrine/horomone check-up?
Do you have any horomone issues I need to be aware of? Example: Low testosterone or estrogen?
Any medications, conditions, physical limitations, etc?
Tell me a fun fact (or two) about you...
All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice from my healthcare provider. I understand that all the information given will be kept confidential.
*
Yes
No
Signature
Clear
Date
-
Month
-
Day
Year
Date
Save
Submit
Print Form
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform