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! 1 Personal Information2 Medical Information3 Exercise Habits4 Eating Habits5 Stress Management6 General Information7 Body Composition Personal InformationYour Name* First Last Your Preferred Email* Your Primary Phone*Alternate Phone (optional)Your Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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?*YesNoWhat types of exercise and what is the duration and frequency of your exercise sessions?*Exercise / ActivitySession DurationFrequency What 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?*Do you eat breakfast?*YesNoDo you use tobacco products?*YesNoHow many tobacco products do you use per week?*At what age did you start smoking?*Do you consume alcohol?*YesNoHow many alcoholic drinks per week?*What types of alcohol?* How 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:* Do you have an eating disorder?*YesNoAre you a vegetarian?*YesNoDo you consume dairy products?*YesNoAre you aware of the number of calories you consume daily?*YesNoHow many?*Have you ever weighed your food?*YesNoDo you read food labels?*YesNoDo you eat out often?*YesNoWhat 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 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?*YesNoHow many hours do you sleep per night?*Do you wake up feeling refreshed?*YesNoIn 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? 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:* 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 %*PhoneThis field is for validation purposes and should be left unchanged.
