Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
What city do you live in?
*
Occupation
*
Height (in)
*
Current Weight (lbs)
*
Ideal Weight (lbs)
*
Are you preparing for a specific upcoming event or making a lifestyle change?
*
How active are you throughout the week on a scale of 1-10?
*
1
2
3
4
5
6
7
8
9
10
How would you rate your current physical condition on a scale of 1-10?
*
1
2
3
4
5
6
7
8
9
10
Do you have any of the following conditions?
*
Please list any injuries, medical conditions, or health concerns we should know about.
Please list any medications or supplements that you are currently taking, and their purpose.
Please list all of your goals. Be specific.
*
What is the most important change you'd like to make to your fitness and lifestyle?
*
Do you have any special requests regarding your program?
Do you have any prior experience working with a fitness professional or trainer?
*
How many days do you currently workout/exercise 25mins or longer throughout the week?
*
1
2
3
4
5
6
7
What do your workouts/exercise/physical activities currently consist of?
*
How many days can you workout/exercise each week? How much time will you have?
*
How many steps do you get each day? (estimated or tracked)
*
<3,000
3,000-6,000
6,000-10,000
>10,000
Do you have a gym membership or plan to get a gym membership? Which gym?
*
Where will be your primary place to workout/exercise?
*
Gym
Home
Apt Gym
Hybrid (50% gym - 50% home)
Park or Field
Do you have any prior experience working with a health coach, dietitian, or nutritionist?
*
Regarding your nutrition, what are the most important things we can help you with?
*
Do you have any food allergies or sensitivities?
*
If yes, please list them.
Do you currently cook or meal prep at home?
*
How many of your meals throughout the week are home cooked?
*
All of my meals
Half of my meals
None of my meals
What are the sources of your other meals? Please be specific.
*
On average, how many ounces of water do you drink each day?
*
40-60oz
60-80oz
80-100oz
100-120oz
> 1 Gallon
On average, how many caffeinated drinks do you consume each day?
*
1
2
3 or more
If you consume caffeinated beverages, please list what they are.
Do you currently follow a specific diet/nutrition plan?
*
N/A
Pescatarian
Vegetarian
Vegan
Paleo
Gluten Free
Dairy Free
What do you currently eat for breakfast, lunch, dinner, and snacks? Please be specific.
*
How many alcoholic beverages do you consume throughout the week?
*
0
1-2
3-4
>5
