Name

Email

Phone

Address

Height

Date of Birth

Place of Birth

Current Weight

Where are you at with your body image?

Weight One Year Ago

Relationship Status

Do You Have Children?
YesNo

Do You Have Any Pets?
YesNo

Occupation

How Many Hours Per Week Do You Work?

Please List Your Main Health Concerns, here’s your chance to get clear on what you want to change
and why?

Other concerns, goals?

At What Point In Your Life Did You Feel Your Best And Why?

Any Serious Illness / Hospitalizations / Injuries?

How is the Health of Your Mother?

How is the Health of Your Father?

What is Your Ancestry?

Do You Sleep Well?

Do You Have Any Pain, Stiffness?

List any supplements / medications currently taking consistently

What roles does exercise play in your life?

What's your food like? Again, be truthful here. This is your time, your space:

Will friends / family support you desire to make lifestyle changes?

What % of your food is home cooked?

Where does the rest of your food come from?

Do You Cook?

Do you crave sugar, coffee, cigarettes or Have Any Major Addictions? How many times a week do you drink (again honesty, please)?

One Thing I Could Change to Improve my Health is?

Biggest Obstacle in my way thus far?

Why does it hold you back?

What was the first thought you had when you woke up this morning?