PERSONAL INFORMATION

First Name *

Last Name *

Email *

Check email regularly? *

Yes

No

Address

Street Address *

City *

State *

Country *

Country

Postal Code *

Age *

Height *

Date of birth *

Place of Birth *

Current Weight *

Weight 6 months ago *

One year ago *

Would you like your weight to be different? *

If so what? *

SOCIAL INFORMATION

Relationship Status *

Single

Married

Divorced

Widow

Name of Partner *

Name / Number of Emergency Contact *

Best days / time to workout / coach *

Children / Pets *

Occupation *

Hrs per week *

I have invested in coaching before(health or other coaching) *

Yes

No

I have invested in gym membership or personal training in the past *

Yes

No

I will take daily action and make daily changes to improve my well-being *

Yes

No

Not sure if I can Commit

I will be open to feedback I receive base on information I provided on this form and stay accountable to this feedback *

Yes

No

Not sure if I can Commit

I understand that improvements to my well-being will require time, persistence and financial commitment *

Yes

No

Not sure if I can Commit

HEALTH INFORMATION

Please list your main health concerns

1. *

2. *

3. *

Top 3 Goals

I *

II *

III *

At what time/age did you feel your best? *

What would a PERFECT day look like? *

Any serious illness/hospitalizations/injuries? *

How is/was the health of your mother? *

How is/was the health of your father? *

What is your ancestry? *

Blood type? *

How is your sleep? *

How many hrs? *

Do you wake at night? *

Any pain, stiffness or swelling? *

Constipation / Diarrhea / Gas? *

Alergies or sensitivities? *

Do you take supplements and/or medications? *

When was the last time you had antibiotics? *

How many times in the last year you had antibiotics? *

Any healers, helpers or therapies with which you are involved *

What role does sports and exercise play in your life? *

FOOD INFORMATION

Cravings? Addictions? *

What food did you eat often as a child?

Breakfast *

Lunch *

Dinner *

Snacks *

Liquids *

What Foods do you eat now?

Current Breakfast *

Current Lunch *

Current Dinner *

Current Snacks *

Current Liquids *

Do you cook? *

Yes

No

Sometimes

What % of your food is home cooked *

Would you like information on better preparation and cooking FIT, Fast, Fresh, Fun healthy meals? *

Yes

No

ADDITIONAL INFORMATION

Anything else you like to share? *

What is 2+ 2 *

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