Assessment Form

Assessment Form

Fill Out The Form and Submit
Date*

MonthDayYear
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
E-mail*
example@example.com
MaleFemale
AGE*
Weight (lbs)measured as of this morning*
Height (Inches)*
Goal weight (lbs)
How many times per week do you exercise?
30 - 45 minutes1.5 hours1 hour2 hours or moreOther
WalkingCardio machinesJoggingStrength trainingPlay SportOther
LIFESTYLE INFORMATION
What do you do for a living?
NoneModerateHigh
YesNo
DaysAfternoonsNights
RarelyFew times per weekFew times per monthWeekly
YesNo
If yes how long ago was it, and how long did it last?
If you have any diagnosed health problems, list the condition(s)
Do you have blood relatives who have had or has any of the following conditions
Do you have any of the following conditions?
Are you taking medication?*
If yes please list medications
What additional therapies or interventions are being taken for the given health problem(s)?
If you have/had any injuries please list them
What additional therapies or interventions are being taken for the given injury(s)?
Do you smoke Tobacco?
If yes how often?
DIET HISTORY
Do you drink alcohol?
If yes how often?
List any food alergies that you have
List foods you like
List foods you dislike
List foods you would eat for one day at breakfast, lunch, dinner, supper and snacks (indicate the time you would eat each meal)
Are you on or have ever been on any special diet?
If yes please state
How often do you grocery shop?
How much money do you spend on groceries per month?
How many meals do you eat per day?
How many meals do you eat in restaurants or fast food places per week?
If you are currently using any nutritional supplements, please list them below, including doses
What change/s would you like to make?*
Please indicate some topics or areas you would want me to focus on.
My Products
prevnext( X )
Smoothie Recipe
Power Break moothie

$2.50 Quantity

Meal Plan
Receive your personalised meal plan designed based on your needs and input

$30.00

Total

$0.00
Should be Empty: