OptiShred Health, Fitness, Nutrition & Lifestyle Assessment
Complete this assessment so a personalised fitness, nutrition, supplement and lifestyle plan can be created using your health, training, nutrition, goals and lifestyle information. The form is designed to be beginner-friendly while still collecting detailed data.
Personal Details
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Female
Male
Non-binary
Prefer not to say
Other
Height (cm)
Current Weight (kg)
Target Weight (kg)
Occupation
Country
Please Select
Afghanistan
Australia
Canada
India
New Zealand
South Africa
United Kingdom
United States
Other
Emergency Contact
Primary Goals
Primary goal
*
Fat Loss
Muscle Gain
Body Recomposition
General Health
Sports Performance
Strength
Endurance
Energy Improvement
Hormone Optimisation
Longevity
Post-Pregnancy Recovery
Other
Top 3 goals
Why achieving this is important
*
Motivation rating
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
What has stopped you achieving your goals previously
Medical History
Diagnosed medical conditions
*
Heart disease
High blood pressure
Low blood pressure
Diabetes
Pre-diabetes
High cholesterol
Low testosterone
Thyroid disorder
PCOS
Endometriosis
Osteoporosis
Asthma
Arthritis
Digestive disorders
IBS
Crohn's disease
Ulcerative colitis
Autoimmune conditions
Mental health conditions
ADHD
Autism
Depression
Anxiety
PTSD
Other
Details about diagnosed conditions
Current medications
Previous surgeries
Current injuries
Previous injuries
Are you currently experiencing pain that affects exercise?
*
Yes
No
Pain details and affected activities
Exercise restrictions or limitations
Doctor's advice regarding exercise
Health Screening
Current health rating
*
Poor
Average
Good
Excellent
Symptom frequency
*
Rows
Never
Rarely
Sometimes
Often
Always
Fatigue
Brain fog
Low motivation
Poor recovery
Joint pain
Muscle aches
Poor sleep
Low libido
Anxiety
Depression
Digestive issues
Bloating
Heartburn
Constipation
Diarrhoea
Headaches
Migraines
Frequent illness
Cold hands and feet
Training History
Years Trained
Current Activity Level
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Current Gym Attendance
Please Select
Never
1-2 times per week
3-4 times per week
5+ times per week
Ever Worked with a Coach?
Yes
No
Current Training Split
Please Select
Full Body
Upper/Lower
Push/Pull/Legs
Body Part Split
Mix of Strength and Cardio
Other
Favourite Exercises
Exercises You Dislike
Equipment Available at Home
Dumbbells
Barbell
Kettlebell
Resistance Bands
Pull-Up Bar
Bench
Treadmill
Exercise Bike
Rowing Machine
Yoga Mat
Other
Gym Membership?
Yes
No
Average Daily Step Count
Cardio Frequency
Please Select
Never
1-2 times per week
3-4 times per week
5+ times per week
Nutrition Assessment
Typical day of eating
*
Meals per day
*
Breakfast
Lunch
Dinner
Snacks
Takeaways per week
Alcohol consumption
Please Select
Never
Monthly
Weekly
2-3 times per week
Daily
Other
Water intake (liters per day)
Coffee intake (cups per day)
Energy drink intake (cans per week)
Do you track calories?
Yes
No
Do you track protein?
Yes
No
Have you followed diets before?
Yes
No
Which diets have you followed?
What worked?
What failed?
Submit Assessment
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