Health Assessment

This is the first step to changing your lifestyle.

Here is the key, you have to be honest so I can help! Fill out the form below so that I can put together a customized plan for you and create the most effective path for you.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Height

Weight

Goal Weight

Are you currently in an exercise program?

Have you ever had surgery or been hospitalized?

Are you currently pregnant or have you been pregnant within the past year? Yes, No, Due Date

Do you have a chronic disease? (diabetes, asthma, hay fever, crohn's)

Has your doctor ever reported that you have a heart condition? Yes, No, Explain.

Name the top 10 foods and drinks you have the majority of the time, honesty is key.

Tell me about your workout regimen, how often, what do you do, if you workout at all.

During physical activity, do you often/occasionally experience

What is most important to you right now?

How were you referred?

Anything else you want me to know?