Assessment

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Initial Client Assessment

Initial Client Assessment

Contact Info

Please add [email protected] to your email safe list. Once you have completed the form, I will contact you.

Please separately send any photos you wish to include to [email protected] (e.g Front, Back and Side Views)

Which service are you interested in ?

Vitality Blueprint - Quick Start

Vitality Blueprint: Healthy Weight Loss and Longevity Program

Bikini Bodybuilding Champion Program

Wellness Bodybuilding Champion Program

Click on Coaching Packages in the top menu for more info.

Full Name *

Mobile Number *

Email Address *

How would you like to communicate for your free consultation booking? *

Phone

WhatsApp

Signal

FB Messenger

Email

Zoom

Google Meet

How did you hear about us or whom has referred you ? *

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Stats

Your Age *

Height (ex: 5 feet, 5 inch) *

Current Weight (in pounds) *

Lowest Ever Weight (in pounds) *

Highest Ever Weight (in pounds) *

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Where do you carry stubborn/hard to lose body fat? (ex: lower abdomen, flanks/love handles, under arm, etc.) *

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Goals, Challenges and Your WHY

What are your health and fitness goal and what really inspires and motivates you to achieve these goals? *

How important is this for you to change? 1 = Not Important 5 = Somewhat 10 = Very Important

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Do you have a specific timeline to achieve your results ? *

Are there emotions you go through when thinking about getting help with your health and fitness goals? *

What are the biggest obstacles you face in trying to achieve your goals? *

What are your reasons for wanting this change? *

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Next

General Health

On a scale of 1-10, How stressful would you consider your overall lifestyle compared to the average person? *

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Have you ever felt any difficulties relating to food in general? *

Do you have any current or past medical issues that would limit your physical activities or nutrition? *

Thyroid Check - Please click the checkbox if the answer is Yes *

My family (parent, sibling, child) has a history of thyroid disease

Women: I have a history of infertility or miscarriage

I am gaining weight for no clear reason

My "normal" body temperature is low (below 98.2° when I take it)

I feel fatigued or exhausted more than normal

I feel depressed, restless, moody, sad

I have a low sex drive

I have a slow pulse, and/or low blood pressure

I have no thyroid issues

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Schedule and Habits

What do you believe is your WORST habit regarding your health? *

What do you believe is your BEST habit regarding your health? *

What time do you go to bed? *

What time do you wake up? *

Detail your average daily schedule *

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Nutrition Info

Please outline your average day regarding nutrition? Include the time of day you eat and how much of each food you consume. *

Do you take any supplements? If so, list them by name and when you take them. (ex: BCAA's, Glutamine, Multi Vitamin, etc.) *

Do you have any known/suspect food sensitivities or allergies? If so, list them. *

Do you have any digestion issues? *

(Symptoms of digestive problems may include abdominal pain, belching, a bloated feeling, a burning sensation after eating, chronic bowel irritation, chronic fatigue, constipation, diarrhea, gas. Heartburn often accompanies indigestion)

How much water do you drink daily? *

List the foods that you like *

List the foods that you absolutely don't like and would not want to be a part of your nutrition plan. *

When and What do you crave the most?

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Next

What kind of physical activities do you do? (ex: weight training, running, yoga, etc.)

Do you have any experience working with Free Weights?

What are some of your weaker lifts?

What are some of your stronger lifts?

How much time do you have to train each day and week?

What time of day do you workout or prefer to workout? *

Please note anything else that you feel would be important for us to know about you and what you want to achieve. (Everything from eating disorders to past contest history. Don't hold anything back. All your information remains private and confidential.) *

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