Please enable JavaScript in your browser to complete this form.Name *FirstLastDateday/monthBirthdayCurrent WeightGoal WeightWhat is your ideal weightAverage BreakfastWhat, how much, and when did you eat? Please include any beverages, including water.Average Morning SnacksInclude any snacks you typically eat in-between breakfast and lunch. Average LunchWhat, how much, and when did you eat? Please include any beverages, including water.Average Afternoon SnacksInclude any snacks you had in between lunch and dinner.Average DinnerWhat, how much, and when did you eat? Please include any beverages, including water.Average DessertPlease include anything you ate or drank before bed.SleepWhat time did you typically go to sleep? Do you have problems sleeping?How many meals per week do you eat out or get carry outsExerciseCardio, weight training, active recreation, daily step count, or anything else active that you wish to list.Food AllergiesPlease list anything that creates an allergic reaction, even if you are not sure, list it here.Current MedicationsList all medicationsSupplementsPlease list all supplements you are currently taking.Current DiagnosisDo you have any medical diagnosis that may affect your weight loss?ObstaclesPlease list anything that you believe will be an obstacle with your food intake.What foods make you feel better?What foods make you feel worse?CommentSubmit Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of BirthAgeHeightSexMaleFemalePrefer not sayTime ZoneFor schedulingGenetic BackgroundEuropeanAfricanNative AmericanMiddle EasternAsianOther*Not RequiredContact Phone NumberEmail *Mailing AddressYour Job and Nature of BusinessExample: 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.Do you smoke cigarettes?NoYesIf so, how many packs per day?Do you drink alcohol?NoYesIf so how much and how often (on average)?example: 3 days per week, 2 drinks per occasion Allergies – Food, Medication, EnvironmentalPlease list all known allergies and your reaction to each.Medical ConditionsSuch as heart problems, diabetes, etc. If so, what?Please describe and injuries, surgeries or general pain and limitations that you currently suffer from or have had in the past.Example: Knee replacement on left knee in 2016.Do you take medications or supplements?YesNoIf so, what?Do you know of any reason you should not begin a training/exercise/nutrition program?In your own words, what is you current fitness level?Do you weight train, do cardio, etc?If you exercise, please describe your exercise program.Example: I do cardio on an elliptical 3 times per week and do a circuit weight training at Curves once per week.Do you understand that this will be a lifestyle change and may take time to reach your results?YesNoOnce 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.How ready are you to make significant changes to better your life?Not readySomewhat readyreadyVery ready!How important is becoming healthier to you?Not importantSomewhat importantVery importantHow supportive are other people in your life for you to make these positive changes?Not supportiveSomewhat supportiveVery supportiveWhat do you hope to achieve with us?What are your immediate and long term goals?Why is achieving this important to you?Have any specific life events caused major changes in your health?YesNoHealth diagnosis, retirement, accident, etcIf yes please explain.What specific foods, activities, or distractions make you feel better?What specific foods, activities, or distractions make your feel worse?Describe any obstacles or potential behaviors or activities that could slow your progress towards accomplishing your goals?How can we help you overcome these obstacles? What is your preferred training location? Inside your houseAt a GymOutsideWhat are the best days of the week for you to commit to training?MondayTuesdayWednesdayThursdayFridaySaturdaySundayMorning ScheduleWhat time do you wake up? Go to work? Eat? Just a general description of your morning.Afternoon ScheduleWhat is your day like? When do you eat? Do you take any naps? Watch TV? Work? Etc.Evening/Night ScheduleWhat is your evening like? What time do you eat dinner? Do you consume alcohol? What time do you go to bed? Etc.Food Log – One Average DayPlease write down what you would eat on an average day, include all meals, snacks, and beverages. Do you follow any special diet or have diet restrictions or limitations for any reason?Health, cultural, religious, or other.Who prepares the majority of your meals?Who shops for food?How many meals per week do you eat at a restaurant or get carry outs?Never1-23-56 or moreThis includes fast foodWhen you eat at home do you preferCooking from scratchSemi-prepared food (ex. simmer pouch, stir fry bags)Frozen mealsWhat foods do you crave?Healthy or notWhat foods do you dislike?List and describe the things that cause you the most stress and anxiety.Stress reliefList the activities or substances that you use to help relieve stress.If you have any additional information to add, please do so here.CommentSubmit
