For scheduling
*Not Required
Example: Sales at a large discount store, I work Monday through Friday from 8-5, I am on my feet all day. We use this to better understand what obstacles to your program may arise.
example: 3 days per week, 2 drinks per occasion
Please list all known allergies and your reaction to each.
Such as heart problems, diabetes, etc. If so, what?
Example: Knee replacement on left knee in 2016.
Do you weight train, do cardio, etc?
Example: I do cardio on an elliptical 3 times per week and do a circuit weight training at Curves once per week.
Once you have reached your goals, you will be able to stick to this program parameters and live a healthy happy life, this is a lifestyle change program, not a fad diet or workout program.
What are your immediate and long term goals?
Health diagnosis, retirement, accident, etc
What time do you wake up? Go to work? Eat? Just a general description of your morning.
What is your day like? When do you eat? Do you take any naps? Watch TV? Work? Etc.
What is your evening like? What time do you eat dinner? Do you consume alcohol? What time do you go to bed? Etc.
Please write down what you would eat on an average day, include all meals, snacks, and beverages.
Health, cultural, religious, or other.
This includes fast food
Healthy or not
List the activities or substances that you use to help relieve stress.