Full Name
Phone
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Email
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Date of birth
Gender
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Male
Female
Height
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Current Weight
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Are you currently taking any oral contraceptives?
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Yes
No
Goal Weight
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Weight History over the last 3-5 years
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Describe what you would like to accomplish with your health & fitness over the next 3 months, 6 months, & 1 year.
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What is your dream goal?
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What have you done in the past to accomplish this goal?
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How long would it take you to accomplish this on your own?
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Do you want to sustain your goal after you achieve it?
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How long have you wanted to achieve your dream goal?
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Why do you want this so badly?
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You already know it's not easy to achieve this goal. Will you take our recommendations and do what we ask in order to help you reach it?
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Yes
No
Why are you applying now?
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Why do you think you'll succeed this time?
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What is your current health state?
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What is your desired health state?
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Have you struggled with maintaining a self-directed fitness program in the past?
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Do you think you'd get better results with an expert helping you along the way?
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Do you think you'd get to your dream goal faster with daily accountability?
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Is it more important that get to your dream goal quickly or that it's permanent?
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Are you married?
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Yes
No
Do you have kids who still live at home?
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Kids
No Kids
Is your spouse aware of the challenges you face with your health?
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Is your spouse supportive when it comes to you improving your health & fitness?
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Would your spouse be totally opposed of you making an investment toward achieving your dream health goals?
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List any previous dieting attempts or nutritional strategies that you have tried. Include the dates and outcome of each as best as you can.
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Have you ever counted calories or micronutriets
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Yes
No
What were those targets?
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In as much detail as possible, describe what a typical day of eating looks like.
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Does your eating differ on the weekends? If so, explain.
Water intake (ounces/day)
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Less than 50oz
50-75oz
75-100oz
100oz +
Alcohol Intake (drinks/week)
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None
1-3
4-5
6+
How often do you eat restaurant food, take-out, or fast food?
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0-2x/week
3-5x/week
6x or more/week
Do you have a tendency to eat when you are bored, upset, or stressed?
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Yes
No
Rarely
Can you explain your bored, upset, or stressed eating habits?
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When it comes to nutrition, what do you feel is most challenging for you?
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Whats your current fitness situation?
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What types of exercise have you participated in in the past?
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Do you have any experience lifting weights and strength training?
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Yes
No
Have you ever followed a structured training program?
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Yes
No
Do you have any specific training goals?
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Do you have any exercise restrictions or limitations?
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Yes
No
Please explain your exercise restrictions.
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What is your current occupation?
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Does it require any of the following:
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Extended periods of sitting
Extending periods of standing
Extended periods of walking
Physical Labor
None of the above
What are your leisure activities?
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When was the last time you had bloodwork done to check your hormones?
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Within the last 6 months
Greater than 6 months ago
Never
On average, how many hours do you sleep per night?
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Less than 5
6-8
More than 8
Do you sleep soundly through the night?
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Always
Majority of the time
Never
Occasionally
Do you wake up feeling rested and energized?
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Yes
No
Do you rely on coffee, energy drinks or other forms of caffeine to make it through your day?
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Rate your stress level on a scale of 1-10 (10 being the highest)
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10
9
8
7
6
5
4
3
2
1
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What are the main stressors in your life?
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Have you frequently experienced any of the following in the last month? Check all that apply.
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Bloating
Belching
Discomfort after eating
Heartburn/Acid Reflux
Diarrhea
Constipation
Gas Pains and/or flatulence
Indigestion
Abdominal Pain
Other...
Do you smoke cigarettes or marijuana?
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Have you ever had any serious injuries? If yes, please explain
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Have you had any surgeries? If yes, please explain
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List any relevant illnesses or medical conditions
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Are you currently taking any medication? If yes, please list the medication and dose
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Are you currently taking any supplements? (including vitamins, minerals, herbs, or sports nutrition supplements.
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Is there anything else you'd like our training team to know?
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