Health Consultation Form
Please have this completed prior to your consult and answer as honestly and with as much detail as possible.
Name
First Name
Last Name
Email
example@example.com
Occupation:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of birth:
Height:
Current weight and overall goal weight:
What are your overall goals?
Recall a time in your life when you felt your best mentally and physically; how much did you weigh and when was it?
List any current or chronic illnesses, diseases or complications you have or had in the past (including mental) that has been diagnosed by a medical professional:
List any allergies you have:
List all surgeries and procedures you have had:
On average how many hours of sleep do you get each night?
Do you drink alcohol? If yes, please list frequency and amount per week
Do you smoke or vape?
Describe what is motivating you to make changes to your current routine?
What obstacles have you been facing that have stopped you from reaching your goals?
List any prescribed medications and vitamins that you are currently taking:
Average amount of water you drink on a daily basis in oz:
Describe your relationship with your diet and activity:
On average, how long have you stuck to a program or protocol before you deviated?
Please list a detailed example of what a normal day of food intake looks like for you (breakfast, lunch, dinner and snacks) :
List activities you currently do or are wanting to start: (Include how many times per week and length of time) and exercise history
Do you feel you are a: beginner, intermediate, or advanced in this area
Beginner
Intermediate
Advanced
How did you hear about my services?
Photos taken during your progress journey may be published to our website, social media, or other material. Do you consent for images and/or videos of you to be marketing and/or promotional purposes?
Signature
Submit
Submit
Should be Empty: