Date of Birth Age Height Sex Male Female Prefer not say Genetic Background
Contact Phone Number Email * Mailing Address Your Job and Nature of Business
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.
If so, how many packs per day? Allergies - Food, Medication, Environmental
Please list all known allergies and your reaction to each.
Such 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? If 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.
Where will you be exercising?
This includes weight training, cardio, and stretching.
Exercise location details
If at home, what will you be using, dumbbells, trx, etc. If you are going to a gym, what gym? Any other details that you feel would help us about your training location.
Do you understand that this will be a lifestyle change and may take time to reach your results?
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.
How important is becoming healthier to you? Tell me about your health goals and what you are hoping to accomplish over the next 12 months. Why are achieving these goals important to you? Have any specific life events caused major changes in your health?
Health diagnosis, retirement, accident, injury, addiction, etc
If yes please describe.
What life event or events have caused changes in your health.
What made you decide now was the time to start working towards your goals? Why not next month or next year? Tell me about the people in your life who will benefit from this investment in your health.
How will this change effect your spouse, partner, children, and/or family?
How supportive are other people in your life for you to make these positive changes? What specific foods, activities, or distractions make you feel better? What specific foods, activities, or distractions make your feel worse? Please list habits in your life currently that will need changing to reach your goals.
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)
How long do you envision it taking to reach your goals?
Where will you be in 6 months? Where will you be in 12 months?
How will your life be different when you reach these goals? Who or what inspires you the most to reach your goals? Why? If you start falling back to old habits, how can we help get you back on track?
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 are the best days of the week for you to commit to training? What is your average daily schedule?
What time do you wake up? Go to work? Eat? Go to sleep? Are you on your feet all day? Watch much TV? etc.
Food Log - One Average Day
Please 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?
This includes fast food
When you eat at home do you prefer What foods do you crave?
Healthy or not
What foods do you dislike? How often do you attend Mass Describe your spiritual habits (prayer, bible reading, etc.) How do you see your life changing with a better connection to God If you have any additional information to add, please do so here.