Street Address Line 2
State / Province
Postal / Zip Code
What is your overall fitness goal? Weight/fat loss, muscle gain, body recomposition, cardiovascular endurance, other?
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.
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?
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?
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?
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?
Have you ever suffered from or been diagnosed with an eating disorder?
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.
( X )
Cut with Me - 2024
Deposit to hold your spot!
Should be Empty: