First Name * Last Name * Age * Email * Cell Phone Number * What is your primary goal? * What do you see being the biggest challenges for you to accomplish your goal? * Are you willing to make sacrifices with your time, your social life, and even your sleep to reach that goal? * Why is that your #1 goal? * Do you have a timeline for achieving your goal? If so, please specify: Additional Comments or Concerns pertaining to your goal(s) Are you doing any workouts currently? *
If so what kind of workouts and at what frequency?
What are your most and least favorite workouts? * Do you have any physical limitations? *
(asthma, bad knees, bad wrists, etc)
Medical and Health Information If you have any diagnosed health problems, list condition(s). Any additional health information. Please list any medications that you are currently taking. What do you do for a living? * Do you work days, afternoons, or nights? * What is the activity level at your job? * Do you travel for your work? If so how often? * Does your job involve shift work * Do you commute to and from your job? Diet and Nutrition Information Do you take any nutritional supplements?
If so, what supplements and what dosage?
How many times a week do you eat out at restaurants? * Have you ever tracked your calories * Do you have any dietary restrictions? *
Is there any other information that you feel I should know about your health, your eating habits, your exercise habits, food sensitivites, etc.?