Email
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example@example.com
Name
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First Name
Last Name
What is your birth date?
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-
Year
-
Month
Day
Date
Where do you live?
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which Coaching Program are you doing at Fitbliss?
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Nutrition Only ($150)
Personalized Programming Only ($150)
All-In ($275)
Lifting Club ($29.99)
Lifting Club + Nutrition ($179.99)
Bodybuilding Contest Prep
Powerlifting Coaching
Other
Do you have an assigned Coach at Team Fitbliss? If yes, who is your coach?
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What is your height and weight?
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Why did you get blood work done? (check all that apply)
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Yearly health screening
Pre exsisting health concerns
I haven't been feeling like myself mentally
I haven't been feeling like myself emotionally
I haven't been feeling like myself physically
I am about to start at fat loss phase
I am about to start a contest prep
I am about to start a sports performance phase
I just finished a fatloss phase or contest prep
I would like to optimize fertility
I would like to optimize metabolism
I would like to optimize muscle building
My coach suggested I should
My doctor suggested I should
Other
What is your profession? What environment(s) do you work in?
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What does a typical day of eating look like for you? (include common foods, quantity of foods and time of day you usually eat).
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Please tell us in a bit more about why you are getting your blood work done as well as your current health and fitness goals and/or concerns:
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What time do you usually go to sleep and wake up?
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How do you feel when you wake up?
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Well rested and positive
Groggy
It depends on when I went to bed
I wake up groggy but feel good once I have caffeine
Other
Please tell us about your morning routine. (first 90 minutes awake) including meals, water, caffeine, time outside, journaling, and the general pace and vibe of your morning.
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Please tell us about your evening routine. (last 120 minutes awake before falling asleep.)
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Do you sleep through the night? If not, please explain how often you wake up and for how long?
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Do you spend any time outside? If yes, when and for how long?
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Please tell us about your exercise routine including resistance training, cardio and steps (if you don't track steps, provide general notes on how much walking you do during the day.)
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Please list ALL medications, birth control, supplements, vitamins and/or HRT or other PED's you take, including the dosages here:
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Please list any past or current health diagnoses (for example: Celiacs, PCOS, Hyperthyroid, High Blood Pressure, Type 2 Dibetes, etc.)
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Please tell us about a time in your life when you felt your very best
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Please list any additional information that will help us understand your goals, lifestyle or questions about your bloodwork.
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Please check all that apply
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I am losing more hair than usual
I have high blood pressure
I have a high resting heart rate
I have a low resting heart rate
I retain a lot of water (4-8# swings)
My HRV is chronically low
I wake up hungry in the morning
I am not hungry until later in the day
I have a regular menstural cycle
I have an irregular menstrual cycle
I am currently going through menopause
I have gone through menopause
I struggle with erectile dysfuntion
I would like to improve my sex drive
I struggle with brain fog
I struggle with anxiety
I struggle with depression
I struggle with intrusive throughts
I am postpartum (1 year or less)
I recently suffered a pregnancy loss
I have been experiencing extreme and chronic stress for the last 3-12 months
My sleep pattern is all over the place
I suspect that I may struggle to lose bodyfat and/or to maintain my weight more that others around me
I would like to be able to put on muscle more easily
I struggle with insomnia
My hunger cues and appetite are all over the place
I often feel stressed and irritable
I often struggle with negativity and "worst case scenario" thinking
I tend to eat the bulk of my calories later in the day, before bed
Please list any additional information that will help us understand your goals, lifestyle or questions about your bloodwork.
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Blood Work Upload (please load ALL blood work you have for the last 5 years)
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Signature + Release of Liability
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Date
*
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Year
-
Month
Day
Date
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