Please fill out this form before our next appointmentPlease enable JavaScript in your browser to complete this form.Name *FirstLastDate of BirthAgeHeightCurrent WeightSexMaleFemalePrefer 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.Golf HandicapHow often do you play?Describe your golf gameAre you competitive? Do you walk the course or ride a cart? Do you drink alcohol when you play? How long does it typically take you to play 18 holes?Describe your warm-up routine.Stretching, range, weighted clubs, etc.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 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.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 mealsIf you have any additional information to add, please do so here.Submit Personal TrainingSpiritual FitnessTPI Golf TrainingFitness Training for CatholicsNutritional Consulting
