Client Assessment

Client Assessment

Complete this form to start your personalized fitness and nutrition journey. Your data will be kept confidential.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex (Assigned at Birth)*
Select your sex assigned at birth to better understand your body’s anatomy and physiology for accurate evaluation and personalized planning. This information helps us tailor strategies based on your biological characteristics.
Occupation*
Work Schedule
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Country of Residence*
Choose the Plan that suits you best

Your selection will allow us to customize the rest of the form to meet your specific needs.
Which plan are you interested in?*

Pure Balance NutritionOnline Personal TrainerOne on One Private Studio (MA. USA)Health & Welness Consulting (online)
Lifestyle & Nutrition Insights

Comprehensive Insights for Personalized Plans
1 - What is your current weight? (in pounds or kilograms)
2 - What is your height? (in feet and inches or meters)
3 - When was the last time you felt comfortable with your weight?
4 -Are there any medications we should consider to personalize your health or training plans?
5 - How often do you consume alcohol?
6 - Do you follow any dietary preferences?
7 - How much water do you drink daily?
8 -How often do you consume processed foods? (canned, packaged, etc.)
9- How often do you eat out?
Eating out refers to consuming meals prepared outside your home, such as at restaurants, work-provided meals, or meals at a friend’s place, etc.
10- Do you follow a specific eating pattern regarding timing, portion sizes, or meal frequency?
11 - Describe everything you ate and drank in the last 24 hours
Exercise & Performance Insights

Understanding your fitness habits and preferences to tailor effective and sustainable training strategies
12 - What is your current physical activity level?

LowMediumHigh
13 -Do you have strength training (weights, gym, etc.)?

YesNo
14 - Where do you usually workout?

At homeGymOutdoorsI do not workout
15 - What type of equipment do you have available for training?

DumbbellsBandsCompat machinesOther
16 - How often do you exercise currently?

Never1-2 times per week3-4 times per week5-6 times per weekDaily
17 - What are your fitness goals? Please provide details such as weight loss, muscle gain, improving endurance, or specific performance targets like running a marathon or lifting a certain weight?
18 - Is there anything we should consider to personalize your training?
19 - What other physical activities do you engage in besides strength training?

HikingRunningSwimmingSoccerTennisOther
20 - How tired do you usually feel during the day

I never feel tiredModerately tiredVery tired
General Wellbeing and Motivation

Understanding your overall wellness and what drives you to achieve your health goals.
21 - How many hours of sleep do you get on average per night?

Less than 5 hours5-6 hours7-8 hoursMore than 8 hours
22 - How would you rate your daily stress levels?

LowModerateHighVery High
23- What motivates you to achieve your health and fitness goals?
24 - Do you have support from friends or family in your fitness journey?

YesNoPartial
25 - Do you prefer individual or group workouts?

IndividualGroupMixed
26 - How many hours per day do you spend sitting?

Less than 4 hours4-6 hours7-9 hoursMore than 9 hours
27 - How often do you consume caffeinated drinks?

NeverOccasionallyFrequentlyDaily
28 - How much time can you dedicate to your daily workouts?

Less than 30 minutes30-60 minutes1-2 hoursMore than 2 hours
Health and Wellness Consulting
1 - What specific health or wellness concerns would you like to discuss? (e.g., stress management, diet improvement, fitness routines)
2 - Are there any particular topics you’d like advice on? (Examples: nutrition, mental health, physical activity)
3 - What are your primary goals for this consulting session? (e.g., setting realistic health goals, understanding your body’s needs, improving overall wellness)
4 - Have you previously consulted with a health or wellness professional? If yes, what were the key takeaways?
5 - What do you hope to achieve from this consultation? (e.g., actionable advice, personalized recommendations, clarity on specific issues)
6 - What is your preferred method of consultation? (Options: Online video call, Phone call)
Your data will be handled with strict confidentiality and used solely to customize your health and wellness plans. The information collected will not be shared with third parties without your explicit consent. By completing this form, you agree to our privacy policy and the use of your data as described.
Should be Empty:

Client Assessment

Choose the Plan that suits you best

Lifestyle & Nutrition Insights

Exercise & Performance Insights

General Wellbeing and Motivation

Health and Wellness Consulting