Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Birthdate
-
Month
-
Day
Year
Date
What is your overall fitness goal? Weight/fat loss, muscle gain, body recomposition, cardiovascular endurance, other?
Height
Inches
Weight
Lbs
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.
Please attach three initial photos; front, side and back. See sample photos below, or take them now.
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Take Photo Back
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Daily Life
Current workout schedule. It's okay if you don't currently have one.
What do you do for physical activity?
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 a week do you work?
How many hours of sleep do you get a night?
What is your daily stress on a level of 1 - 10?
What are your current hobbies/interests?
What do you enjoy doing for physical activity?
Do you have any trips planned between January XX and February XX?
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Diet
Current Calories/Macros:
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?
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General Health
When was your last up to date physical with bloodwork?
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?
Any medications, conditions, physical limitations, etc?
Have you ever suffered from or been diagnosed with an eating disorder?
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All the information on this form is correct and to the best of my knowledge. I understand that all the information given will be kept confidential.
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Date
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Month
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Day
Year
Date
Signature
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