General Information

First Name *

Last Name *

Height *

Current Body Weight *

Age *

Current Occupation *

Address *

Email address

Cell Phone Number

Experience & Goals

This is where we will gain a firm understanding of your experience level to help us assess training programming, along with what your specific goals are.

Give us a detailed description of your goals (fat loss, muscle gain, compete, target areas, timeline). For the most part fat loss and muscle gain are separate goals so please choose only one. *

How Many Years Have You Weight Trained *

I don't currently

Less than 1 year

1-3 years

3-6 years

More than 6 years

Training Information

What is your current training regimen like? How you feel it is working for you. *

What access do you have in terms of exercise equipment available? Do you live in an area where you can go on a walk in the morning? *

What type of cardio do you prefer? *

LISS - Low Intensity Steady State (Treadmill walk, elliptical, stepper, Jog, etc....)

HIIT - High Intensity Interval Training - Circuits - much more intense/ higher heart rate, shorter duration

Screw Cardio Seriously - Would rather not....

List any exercises to avoid in the design of your program *

Do you have access to a full gym? *

Yes

If you answered no, what equipment do you have access to - Please list (for example: Squat Rack, Barbells, Strength Machines, Dumbbells, kettlebells, Medballs, Rowing Machine, Spin Bike, Bands Etc)

How many days per week are you currently training? *

Nutritional Information

If you know your current macronutrient intake breakdown please provide the amounts of Fats/Carbs/Protein. If you don't know the macros, try to give me an estimated daily calorie intake. If you are not sure, I'd prefer you to say n/a than taking a wild guess. This will only help if your fairly sure and specific.

In regards to your current food intake, have you been gaining, losing, or relatively maintaining your weight? *

Indicate your activity level below. This is to determine your non exercise related energy expenditure, on top of lifting. Basically, how active you are during the time away from the gym. *

Sedentary and no other exercise

Sedentary plus 3-6 days of weight lifting/exercise

Lightly active, plus 3-6 days of weight lifting/exercise

Active plus 3-6 days of weight lifting/exercise

Very active plus 3-6 days of weight lifting/exercise

Out of all of the changes you would like to make what is the most urgent and why?

List any current supplements or doctor prescribed medications that you are taking. PLEASE LIST EVERYTHING- this will only stay between us, and it is important for me to know every piece of information regarding any medications your using. *

If you have been tested for or know of any food related sensitivities or allergies, please list them below.

Any other information that you could provide that you feel would be vitally important in your program design please list below.

Do you have a regular menstrual cycle? If not, please explain.... Are your on hormonal birth control or HRT?

On a scale of 1-10 right now, how much do the people and things around you support your health, fitness, and/or behavior change?

On a scale of 1-10 how would you rank your sleep quality? *

On a scale of 1-5 How READY are you to change your behavior habits?

On a scale of 1-5 How ABLE are you to change your behaviors and habits?

On a scale of 1-5 How WILLING are you to change your behavior habits?

Please describe your current level of stress environment on a scale from 1-10. (1 being no stress, 10 being constantly about to explode) *