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Name
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Email
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Height (ft)
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Height (in)
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Current Body Weight (lbs)
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Desired Body Weight (lbs)
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Highest Body Weight (lbs)
Lowest Body Weight (lbs)
What are your nutrition and fitness goals?
What have you tried in the past to achieve your nutrition and fitness goals? This includes any diet or exercise program, supplement use, books, etc...
What are the drivers behind wanting to achieve your goal?
What have been the barriers or challenges delaying you from achieving your goal?
What are your hobbies or favorite things to do?
Please list any relevant past medical history and current medications: i.e. food allergies/intolerances, high cholesterol, diabetes, heart disease, ADHD, hypo/hyperthyroidism, recent surgeries, bowl disease, depression, eating disorders, recent athletic injuries, anemia, etc...
List all vitamin/mineral supplements you currently take?
List any food restrictions or any foods that you avoid?
On average, about how many hours do you sleep:
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Are you currently stresses?
Yes
No
About how stressed are you daily?
A little
Moderate
Very
Extremely
None
How do you manage your stress?
Do you currently have a gym membership? If Yes, where?
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Yes
No
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Do you plan on purchasing a gym membership in the near future?
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Yes
No
Are you currently on an exercise program?
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Yes
No
What exercises/program are you doing each day?
What does a normal day of eating look like for you? Please include portion sizes and brands if it is possible.
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