TJTemperTraining Client Health & Goals Assessment
Your answers help me understand where you are today so I can guide you toward feeling, performing, and living at your best.
Website:
www.tjtempertraining.com
Phone:
614-716-9185
Basic Info
Full Name
*
First Name
Last Name
Age
*
Birthday
*
-
Month
-
Day
Year
Date
Occupation
Current Weight (lbs)
*
Goal Weight (lbs)
*
Activity Level
*
Low
Moderate
High
SECTION 1 – Your Top Priorities
What are your top 3 outcomes you want to achieve?
*
Fat loss
Energy
Cravings
Sleep
Recovery
Appearance
Aging
Other
How important are these outcomes to you?
*
Not at all
1
2
3
4
Very Important
5
1 is Not at all, 5 is Very Important
SECTION 2 – Weight & Metabolism
What is your biggest challenge with weight management?
*
Struggling to lose
Struggling to maintain
Fluctuating weight
Other
How often do you experience weight creep (gradual weight gain)?
*
Never
Rarely
Sometimes
Often
Do you struggle with food noise (constant thoughts about food)?
*
Never
Occasionally
Frequently
Have you regained weight after losing it?
*
No
Yes, once
Yes, multiple times
Have you tried GLP1 medications?
*
Yes
No
SECTION 3 – Energy & Mood
How often do you feel fatigued?
*
Never
Occasionally
Frequently
Do you experience brain fog?
*
Never
Occasionally
Frequently
How often do you feel stressed?
*
Rarely
Sometimes
Often
SECTION 4 – Recovery
Do you experience slow recovery after exercise?
*
Never
Sometimes
Often
Do you experience joint pain?
*
Never
Occasionally
Frequently
Any past injuries?
*
SECTION 5 – Sleep & Immune
How would you rate your sleep quality?
*
Excellent
Good
Fair
Poor
How often do you get sick?
*
Rarely
Occasionally
Frequently
Are you exposed to toxins (e.g., chemicals, smoke, pollution) regularly?
*
Yes
No
SECTION 6 – Aging
Are you concerned about aging?
*
Not at all
A little
Somewhat
Very
Have you noticed changes in appearance due to aging?
*
No
Some
Significant
Are you interested in longevity and healthy aging?
*
Yes
No
SECTION 7 – Microdosing Fit
Which best describes your current weight situation?
*
Stable
Slowly increasing
Slowly decreasing
Rapidly increasing
Rapidly decreasing
Which has a bigger impact for you: hormones or habits?
*
Hormones
Habits
Both equally
Not sure
Do you have any microdose preferences or experiences?
*
SECTION 8 – Medical
Do you have any restrictions for GLP1 medications?
*
Yes
No
If yes, please explain your GLP1 restrictions.
*
Please select any medical diagnoses you have received.
*
Diabetes
Thyroid disorder
Hypertension
Heart disease
Autoimmune
Other
Are you currently pregnant?
*
Yes
No
Prefer not to say
Please provide any additional health notes.
*
List any medications you are currently taking.
*
Final
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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