Fitbliss Blood Work Form

Email*
example@example.com
Name*

First NameLast Name
What is your birth date?*

YearMonthDay
Date
Where do you live?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which Coaching Program are you doing at Fitbliss?*

Nutrition Only ($150)Personalized Programming Only ($150)All-In ($275)Lifting Club ($29.99)Lifting Club + Nutrition ($179.99)Bodybuilding Contest PrepPowerlifting CoachingOther
Do you have an assigned Coach at Team Fitbliss? If yes, who is your coach?*
What is your height and weight?*
Last Menstrual Period prior to date of blood work (if applicable):

MonthDayYear
Date
Why did you get blood work done? (check all that apply)*

Yearly health screeningPre exsisting health concernsI haven't been feeling like myself mentallyI haven't been feeling like myself emotionallyI haven't been feeling like myself physicallyI am about to start at fat loss phaseI am about to start a contest prepI am about to start a sports performance phaseI just finished a fatloss phase or contest prepI would like to optimize fertilityI would like to optimize metabolismI would like to optimize muscle buildingMy coach suggested I shouldMy doctor suggested I shouldOther
What is your profession? What environment(s) do you work in?*
What does a typical day of eating look like for you? (include common food sources, quantity of foods and time of day you usually eat).*
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:*
How many hours of sleep do you average a night? What time do you usually go to sleep and wake up?*
How do you feel when you wake up?*

Well rested and positiveGroggyIt depends on when I went to bedI wake up groggy but feel good once I have caffeineOther
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.*
Please tell us about your evening routine. (last 120 minutes awake before falling asleep.)*
Do you sleep through the night? If not, please explain how often you wake up and for how long?*
Do you spend any time outside? If yes, what does your outside time throughout the week look like and how long are you outside? *
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.) *
Do you drink caffeine? If yes, how much and how often?*
Do you drink alcohol? If yes, how much and how often?*
Do you smoke? If yes, how many packs per day?*
Do you use any other substances? If yes, what do you use, how much, and how often?*
Please list ALL over the counter and prescribed medications, birth control, supplements, vitamins and/or HRT or other PED's you take here. Please include dosages, frequencies, and strengths. (Please list brand name if taking any supplements with multiple ingredients.)*
Do you have any food or medication allergies? If yes, please list food or medication and describe what happens.*
Please list any past or current health diagnoses and past surgeries. (for example: Celiac, PCOS, Hyperthyroid, High Blood Pressure, Type 2 Diabetes, etc.)*
Please tell us about a time in your life when you felt your very best*
Please list any additional information that will help us understand your goals, lifestyle or questions about your bloodwork.*
Please check all that apply*

I am losing more hair than usualI have high blood pressureI have a high resting heart rateI have a low resting heart rateI retain a lot of water (4-8# swings)My HRV is chronically lowI wake up hungry in the morningI am not hungry until later in the dayI have a regular menstural cycleI have an irregular menstrual cycleI am currently going through menopauseI have gone through menopauseI struggle with erectile dysfuntionI would like to improve my sex driveI struggle with brain fogI struggle with anxietyI struggle with depressionI struggle with intrusive throughtsI am postpartum (1 year or less)I recently suffered a pregnancy lossI have been experiencing extreme and chronic stress for the last 3-12 monthsMy sleep pattern is all over the placeI suspect that I may struggle to lose bodyfat and/or to maintain my weight more that others around meI would like to be able to put on muscle more easilyI struggle with insomniaMy hunger cues and appetite are all over the placeI often feel stressed and irritableI often struggle with negativity and "worst case scenario" thinkingI tend to eat the bulk of my calories later in the day, before bedNone of the above
Please list any additional information that will help us understand your goals, lifestyle or questions about your bloodwork.*
How familiar are you with medical terminology?*
What level of detail would you like for your review?*
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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