Khronology Functional Fitness and Nutrition Initial Fitness and Nutritional Assessment
Name:
First Name
Last Name
Email:
example@example.com
DOB:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Gender:
Height:
Weight:
Usual Weight:
Desired Weight:
Have you gained or lost weight recently ?(y/n)
What are your main personal health concerns, in order of importance? Have you received any treatment for these concerns?
If so, why?
Please indicate if you or a family member has had any of the following now or in the past, along with years affected if known:
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Specified Relative
Disease
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Do you use tobacco products?(y/n)
If yes, how much and what type?
Do you have any recent lab result(s) you would like to share? (cholesterol, blood sugar, blood pressure, etc)
Current Medications: Name
Dosage
For what?
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Current Supplements / Herbs / Vitamins: Name
Dosage
For what?
1
2
3
Dosage
Please list any alternative treatments you are undertaking
Number of bowel movements per day :
Do you have cravings?(y/n)
If so, what kind of food(s)?
Do you have any food allergies or sensitivities? (y/n)
If so, what kind of food(s)?
How many times per day do you eat (include a meals and snacks)?
Do you ever skip meals? (yn)
If so, which ones and why?
Have you ever been on a modified diet (vegan/vegetarian; Paleo; weight watchers; raw food; Atkins, etc)? Please list all
Do you generally cook your own meals? (yn)
Where do you usually grocery shop?
How would you describe most meals? Relaxed? Rushed? At table? In front of TV? In car? Alone? With family/friends?
What is your relationship with food? (example - do you "live to eat" or "eat to live"?)
Do you need caffeine / sweets in the afternoon?
How often do you exercise (times per week)?
How long are your exercise sessions?
What type of exercises do you do?
Do you have any reasons you should NOT do physical activity?
How often do you engage in stress relieving activities? (times per month)
What do you do?
How many hours of sleep do you get on average per night?
Do you feel your sleep is restful?
Do you have any difficulty falling asleep, staying asleep or waking up in the morning?
What is your usual bed time?
Waking time?
How would you rate your energy level on a scale of 1 (low) to 10 (high)
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Please indicate by highlighting if you have any of the following symptoms:
Untitled Matrix
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PLEASE LIST ANY OTHER BOTHERSOME SYMPTOMS
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1. What are your major fitness goals? [circle all that apply]
Fat loss / Muscle gain
General fitness
Functional fitness
Aerobic conditioning
Muscular endurance
Muscular strength
Improved flexibility
Other
2. What is your current level of fitness? [What is fitness level? Your fitness level means your body's ability to withstand a physical workload (how much) and to recover in a timely manner.] 0-Decoditioned-never worked out 1-novice 2-internediate 3-advanced 4-athlete
3. Are there any body parts that you would like to focus on?
Legs
Arms
Butt
Abs
Chest
Other
1)
2)
3)
5. How long after beginning your training do you expect to see/feel changes in your body?
1 week
2 weeks
4 weeks
6 weeks
6. Do you have a specific event/date you are focusing on for your fitness goals?
7. How would you describe your current knowledge of exercise and fitness training?
I am not familiar
I have a little experience
I am quite experienced
I am an expert
8. If you currently exercise, would you say your routine is:
Ineffective
Effective
Very Effective
9. What will motivate you to achieve your fitness goals?
10. How motivated are you to achieving your goals?
Least
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2
3
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5
Most
11. What, if any, are your expected barriers towards your exercise program? (E.g. long work hours, lack of facilities or time)
I understand and acknowledge that recommendations and services provided are done so solely for the purpose of wellness and prevention, and is in no way intended to diagnose or treat serious medical conditions. All information will be kept strictly confidential.
Electronic Signature:
Date:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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