Name
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First Name
Last Name
Email
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Phone
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(###)
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Date of Birth
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MM
DD
YYYY
Height (feet and inches)
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Weight (pounds)
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What are your goals?
Check all that apply
Please describe any concerns about your fitness, performance, and/or body.
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Out of the concerns above, which ones feel the most important? Why?
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What do you expect from me?
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What are you prepared to do to work toward your goals?
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Have you tried anything in the past to change your fitness, performance, and/or body?
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If so, what have you tried?
Which of those things worked well for you?
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Even if you might not be doing it right now.
Which of those things didn't work well for you?
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Why didn't they work?
How would you like your fitness, performance, and/or body to be different?
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What has blocked you or held you back from changing these things?
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Which of the following best describes your eating or nutrition habits?
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Why?
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Aside from strength training and/or cardio, what other types of movement or activities do you do?
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How frequently do you do them, and for what duration?
Have you have been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?
If so, what are they?
Are you taking any prescription medications?
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If so, what are they?
Are you taking any over-the-counter or sports supplements?
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If so, what are they?
Why?
On average, how many hours do you sleep per night?
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How do you normally cope with your stress?
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Medical Disclaimer
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Please recognize that it is your responsibility to work directly with your health care provider before, during, and after seeking nutrition and / or fitness consultation. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept full responsibility for your decision.
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