Health Assessment

Congratulations, you’ve taken the first steps toward a healthier you. The first step is always the scariest, but you’ve done it. Before you know it, you’ll be stepping out in style with a new outlook on life; feeling good and looking good. Improve your strength and flexibility, downsize to upgrade that wardrobe and gain back that self esteem.

Where do we begin? I need you to take just 10 minutes of your time. 10 minutes that can change your future health and well being. Complete the question in the form I’ve provided. Just click the button above.

Honesty counts, I want real answers, you know the ones you want to deny or pass off as unimportant. Well they’re important to me as I customize your plan.

Let’s get started.

Fitness Intake Form

Please answer the following questions as completely and honestly as possible.

Full Name *

Phone *

Email *

Age *

Current Weight *

Goal Weight *

Height *

What do you expect from your training?

What are your biggest roadblocks?

What are your biggest strengths?

What are your biggest concerns?

Diet

What types of food do you eat every day?

Do you know how many calories you eat in a day?

Yes

Calories

Grams of carbs

Grams of fat

Grams of protein

What time of day do you normally eat?

Breakfast

Lunch

Snack

Dinner

Snack

Other Meals

Please list foods you like:

Please list foods you dislike/cannot eat:

Do you have any food allergies?

What supplementation and vitamins do you take?

What has your past 3 days eating been; morning to night? This includes anything you put in your mouth. Also record what you drank. Take your time, this part is important.

Exercise

Do you require a doctor’s release in order to exercise? *

What cardiovascular exercise do you normally do (if any) including what machines normally use? Do you run? Bike? How many minutes or how far? Days per week?

Do you weight train? If so how often? *

What muscles are your strength and what are weaknesses or areas you feel you need to focus on?

What equipment or gym do you have available to use?

Can you do cardio on days you are not in the gym?

Daily Routine

What time do you?

Wake Up

Workout

Cardio

Bedtime

Prescription Medicines (include hormones, sleep aids, anxiety or depression medicines)

Describe any injuries you have.

List any surgeries I should know about.

Do you have any physical limitations?

Anything else that you think is important for me to know.

Thank you for your interest in training with me. Your form has been submitted and I will be reviewing it shortly. Please allow me 24-48 hours to respond.

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