Name *

First Name

Last Name

Cell Phone *

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What time do you normally wake up? *

Hour

Minute

Second

AM PM

What time do you normally go to sleep? *

Hour

Minute

Second

AM PM

Do you have high cholesterol? *

Yes

No

Has your doctor ever said that you have heart trouble? *

Yes

No

Has your doctor ever told you that you have a bone or joint problem (such as arthritis) that has been or may be exacerbated by physical activity? *

Yes

No

Has your doctor ever told you that your blood pressure was too high? *

Yes

No

Have you had any injuries, surgeries and/or hospitalizations in the last two years? *

Yes

No

Is there any reason, not mentioned thus far, that would not allow you to participate in a physical fitness program? *

Yes

No

Do you ever feel weak, fatigued, or sluggish? *

Yes

No

Do you know what you eat in macros each day? *

Yes

No

Do you eat breakfast? *

Yes

No

Are you taking supplements? *

(i.e. vitamins, amino acids, protein shakes, etc.)

Yes

No

Do you crave __________ *

Salty/Savory

Sweet

Both

Is food texture important to you? *

Yes

No

Do you need several cups of to keep you going throughout the day? *

Yes

No

Do you often experience digestive difficulties? *

Yes

No

Are you sensitive and/or allergic to gluten? *

Sensitive

Allergic

Neither

Proper nutrition can increase the body’s ability to enhance physical and mental performance by up to 80%. Do you feel that a properly structured nutrition and exercise program would benefit you? *

Yes

No

Have you reached and maintained your goals? *

Yes

No

Are you happy with the way you look and your health? *

Yes

No

What time of day do you like to exercise? *

Hour

Minute

Second

AM PM

What makes it difficult for you to exercise on a regular basis? *

Please check all that apply

Knowledge

Motivation

Discipline

Accountability

Intimidation

Boredom

Time

I would like to: *

Please check all that apply

Increase muscle tone

Lose body fat

Increase stamina

Increase strength/lean mass

Improve overall health

Which of the following statements best describes you? *

I can eat almost anything I want and won’t gain weight. It is very hard for me to gain weight.

I can lose or gain weight by adjusting my activity level and eating habits.

I find it difficult to lose weight. I can gain weight easily and have to watch what I eat.

Please check off all that apply to your eating: *

Low Fat

Low Carb

High Protein

Low Sodium

No Gluten

Vegetarian

Vegan

High Raw

Diabetic

Pre-Diabetic

No Dairy

Paleo

Pescatarian

Other

Eating Style – Based on how you eat on a regular basis, please check all that apply: *

Fast Eater

Erratic Eater

Emotional Eater (stressed, bored, sad, etc.)

Late–Night Eater

Negative Relationship with Food

Do Not Plan Meals/Menus

Family Member(s) Have Different Tastes

Self–Proclaimed Foodie

Rely on Convenience Items

Time Constraints

Dislike “Healthy” Food

Confused about Food/Nutrition

Frequently Eat Fast Food

What do you consider yourself to be? *

A grazer

A 3 square meals kinda person

Somewhere in between

Have you ever worked with a personal trainer and/or have you ever been placed on any type of nutritional program in the past?

Yes

No

Please close your eyes and visualize the EXACT physique you want to have. Have you ever had this look before? *

Yes

No

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