Name

E-mail

Phone Number

Male/Female
Male
Female

Height:

Weight:

Body fat (if known):

Date of birth:

Occupation:

Number of hours worked per week:

Pertinent Medical History: Any surgeries, illnesses, allergies, medications, do you smoke, consume alcohol, caffeine, illicit drugs, supplements, Please elaborate:

Do you have any current injuries? Do you feel pain or discomfort? When is it bothersome? Please explain:

What is your general feeling of well being? Please explain:

What is your family history? Any known medical conditions?

How often do you exercise?
I workout 5 times a week or more
I workout about 1-2 times per week
I have not worked out for 1-3 months
I have not worked out for 1-3 years
I have not worked out for 3-5 years
It has been over 5 years

My typical workout consists of:
aerobics
machines
free weights
walking
jogging
swimming
bicycling
athletics
I do not currently exercise

Please explain your typical workout. How often do you train with weights/machines? How often do you do cardio? How often do you work each muscle group? How long have you been doing this current routine? Do you every vary your workout? Please include anything else you think is relevant:

Please describe a typical day of eating and how many meals per day you eat: (An easy way to do this is to write down everything you ate today or keep track of it tomorrow, but please be honest)

What are your goals?
Lose weight
Increase muscle
Add tone and definition
Increase energy
Relieve pain
Decrease bodyfat
Gain strength
Improve endurance
Lower cholesterol

Please use this space to explain in more detail the specific results you wish to achieve:

Do you have anything you would like to add?

Thank you for filling out the questionnaire. I will review your answers and a program will be designed for you within 5 days. If you have not already paid for your program you will receive an email with instructions and a link to the PayPal site location to make your payment.