Health Assessment

Health Assessment

This is designed to just get a little info about you..
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Age
years
Contact number
Weight
KG
What do you do for a living?
Whats the activity level at your job?
Email
example@example.com
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often do you travel?
Please list the physical activities that you participate in outside of the gym and outside of work.:
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
Any known food allergies?
If you had to rate your sleep 1-5 what you rate it and why?
Are you experiencing any stresses or motivational problems?
Do you generally maintain healthy habits nutritionally?

Other
Energy Levels
Do you suffer from diabetes, asthma, high or low blood pressure?
Please list:
What Liquid drink will find difficult to stop drinking?
Your current diet could be best characterized as:
Please rate your readiness for change.
What following goals does best fit in with your goals?
What is your goal weight?

TImeline for achieving your goal.

Rows	8 WKS	16 WKS	24 WKS	32 WKS	40 WKS	1 YEAR
NOW

How much water do you drink daily? ( 16-23oz 32-48oz, 64oz or more)
Please rate your motivational level to do what it takes for reach your goal.
Do you believe your current nutritional lifestyle and habits are holding you back from things you want to do in life?
If you workout how often do you work out?
Should be Empty: