Consultation Form
Name:
Date:
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about A. Rae Fitness?
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Age:
Weight:
Height:
Any doctor diagnosed diseases/conditions:
List of current medications:
List of current supplements and vitamins:
If applicable, are you currently on any type of birth control?
Do you smoke? If so, how much per day/week?
Alcohol intake per week, in number of drinks:
Current average water intake PER DAY, in ounces:
Current average caffeine intake PER DAY, in milligrams? What sources do you intake caffeine from?
Do you have any food sensitivities or intolerances? If YES, what?
Do you currently experience any GI symptoms such as: bloating, gas, diarrhea, constipation, abdominal cramping, etc.? Do you have DAILY bowel movements?
Are there any foods that you won't eat or don't like? This is important for a lifestyle and sustainability approach, so please be detailed.
Current sleep: on a scale of 1-10, 10 being the BEST, how would you rate the current quality of your sleep and why?
On average, how many hours per night of sleep do you get?
If interested in personal training, how many times a week are you looking for, and what days/times are you available to train (hour long sessions)?
Do you have a TOTAL MONTHLY budget you would like to stick with? If so, please list a range below.
1. What is your current activity level? (Lifting, cardio, sports?) Include how many days a week and length. Be specific.
2. What kind of job do you have? Sedentary or active? Explain what you do, and how many hours a week you work.
3. What does an average day of eating look like for you? List each meal, including snacks, and what it usually contains. Be as specific as possible, as this gives me a baseline of where we are at currently.
4. Weaknesses: Time of day/ type of food: Where are your struggle times of the day/experiencing the most cravings? When you do get cravings, what is it you crave? (Sweet, salty, fried, etc). Explain your downfalls and when they happen so I can coach you on how to avoid these times and how to prepare yourself for them.
5. This is probably the most important question: What are your short term and long term goals? What caused you to reach out? WHAT IS YOUR WHY? Be specific.
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