Get Your FREE Training and Lifestyle Evaluation Simply complete your profile below. Once you've finished, click to submit, and we'll take it from there! FacebookThis field is for validation purposes and should be left unchanged.Personal InformationYour Name* First Last Your Preferred Email* Your Primary Phone*This field is hidden when viewing the formAlternate Phone (optional)This field is hidden when viewing the formYour 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 List any medications (prescribed and/or over the counter) you are currently taking and when you first started taking them:*MedicationDate Started Exercise HabitsDo you exercise regularly?* Yes No What types of exercise and what is the duration and frequency of your exercise sessions?*Exercise / ActivitySession DurationFrequency This field is hidden when viewing the formWhat types of exercise equipment do you have at home? What times can you exercise throughout the week (check all that apply)?* Morning Afternoon Evening Flexible Eating HabitsHow many meals do you have per day?*This field is hidden when viewing the formDo you eat breakfast? Yes No This field is hidden when viewing the formDo 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?* How many caffeinated beverages do you drink per day?*This field is hidden when viewing the formHow many non-diet sodas do you drink per day?How many ounces of water do you drink a day*This field is hidden when viewing the formList any food allergies: This field is hidden when viewing the formDo you have an eating disorder? Yes No This field is hidden when viewing the formAre 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?*This field is hidden when viewing the formHave 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?* Do 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 This field is hidden when viewing the formHow 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?*This field is hidden when viewing the formWhen do you arrive at work?This field is hidden when viewing the formWhen do you eat lunch?This field is hidden when viewing the formWhen do you leave work?When do you go to bed?*This field is hidden when viewing the formWhen is your morning workout?This field is hidden when viewing the formWhen is your morning scheduled break (a.m.) ?This field is hidden when viewing the formWhen is your afternoon scheduled break (p.m.) ?When do you workout?*General InformationThis field is hidden when viewing the formList your hobbies or recreational activities: What 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:* Body CompositionPRESENT Weight*PRESENT Body Fat %*GOAL Weight*GOAL Body Fat %*
