Please fill out this form before our next appointment

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.
Health diagnosis, retirement, accident, injury, addiction, etc
What life event or events have caused changes in your health.
How will this change effect your spouse, partner, children, and/or family?
Tell me about some habits you will need help adjusting to reach your monthly goals. (e.g. fast food, smoking, alcohol, watching too much T.V. at night, etc)
Where will you be in 6 months? Where will you be in 12 months?
In the next year, when the going gets tough and you are having a hard time coming in, what can we say or do that will motivate you to get back on track?
What time do you wake up? Go to work? Eat? Go to sleep? Are you on your feet all day? Watch much TV? 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
Personal Training

Personal Training

Life Coach

Spiritual Fitness

Golf Training

TPI Golf Training

Mindfulness Classes

Fitness Training for Catholics

Nutritional Consulting

Nutritional Consulting