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"*" indicates required fields Personal InformationYour Name* First Last Your Preferred Email* Your Primary Phone*Alternate Phone (optional)Your Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Occupation* Your Height* Your Birthday* Medical InformationDo you consider your health to be...*ExcellentGoodFairPoortList any present or past illnesses, injuries or conditions and when they initially occurred:*Illness / Injury / ConditionDate Add RemoveList any medications (prescribed and/or over the counter) you are currently taking and when you first started taking them:*MedicationDate Started Add RemoveExercise HabitsDo you exercise regularly?* Yes No What types of exercise and what is the duration and frequency of your exercise sessions?*Exercise / ActivitySession DurationFrequency Add RemoveWhat types of exercise equipment do you have at home?* Add RemoveWhat times can you exercise throughout the week (check all that apply)?* Morning Afternoon Evening Flexible Eating HabitsHow many meals do you have per day?* Do you eat breakfast?* Yes No Do you use tobacco products?* Yes No How many tobacco products do you use per week?* At what age did you start smoking?* Do you consume alcohol?* Yes No How many alcoholic drinks per week?* What types of alcohol?* Add RemoveHow many caffeinated beverages do you drink per day?* How many non-diet sodas do you drink per day?* How many glasses of water do you drink per day?* List any food allergies:* Add RemoveDo you have an eating disorder?* Yes No Are you a vegetarian?* Yes No Do you consume dairy products?* Yes No Are you aware of the number of calories you consume daily?* Yes No How many?* Have you ever weighed your food?* Yes No Do you read food labels?* Yes No Do you eat out often?* Yes No What types of restaurants?* Add RemoveDo you ever experience (check all that apply):* Regular Overeating Snacking at Night Strong or Persistent Hunger Occasional Binge Eating Regaining Weight Easily Eating Rapidly Difficulty Knowing When Your Stomach is Full Craving High-Fat or High-Sugar Foods Gaining Weight on Less Food Gaining Weight After Pregnancy / Birth Control / Estrogen None of the Above Stress ManagementAre you...*The impact of stress on our overall health and well being can't be underestimated. Every day, we face both physical and psychological stress. Some kinds of stress are out of our control; others may be triggers we aren't consciously aware of. Regardless of the source of stress, it must be managed to achieve maximum health and fitness. The first step is look for and acknowledge the stress triggers in our lives. Please answer these questions, using a scale from 1-5, where 1 is "Strongly Agree" and 5 is "Strongly Disagree".Strongly disagreeDisagreeNeutralAgreeStrongly agreeImpatient?Moody / hard to get along with?Anxious?Able to quiet your mind?Happy and content with life?Fulfilled and satisfied?Focused and on task? Do you sleep well?* Yes No How many hours do you sleep per night?* Do you wake up feeling refreshed?* Yes No In the last year have you experienced... (check all that apply)* Death of someone close? Arrested/served jail time? Loss of job? Aging parent? Financial difficulties? Changed job/profession? Caregiving for someone infirmed? Divorced or relationship breakup or issues? Injury or illness? Lawsuit or legal proceedings? Family conflict? Victim of crime? Changed your residence? None of the Above How do you relax? (check all that apply)* Read Workout/ physical activity Gardening/ yard work Care for pets Participate in sports Hang out with friends Draw/ paint/ arts and crafts Use drugs Cook/ bake Listen to music Go to movies Meditate Drink alcohol Yoga/ GiGong Watch television Sew/ knit Shop Organized religion When do you wake up?* When do you arrive at work?* When do you eat lunch?* When do you leave work?* When do you go to bed?* When is your morning workout?* When is your morning scheduled break (a.m.) ?* When is your afternoon scheduled break (p.m.) ?* When is your evening workout?* General InformationList your hobbies or recreational activities:* Add RemoveWhat are your specific goals? (check all that apply)* Lose Body Fat Build Muscle Mass Tone & Define Improve Coordination Sports Related Skills Other List your other goals:* Add RemoveBody CompositionPRESENT Weight* PRESENT Body Fat %* GOAL Weight* GOAL Body Fat %* CommentsThis field is for validation purposes and should be left unchanged.
