Today’s Date
Full Name
Email
Phone Number
Gender
Age
Height
Weight
Body Fat % (if known)
WEEKLY EXERCISE PROGRAMS
Explain what type of resistance exercise, cardiovascular or sports activities you perform during an average 7-day period
Do you have weight lifting experience?
Do you have access to a gym?
If not, do you have a home gym?
If not, what type of exercise equipment is at your access?
LIFESTYLE/PROFESSIONAL ACTIVITY
What are your goals
What is your goal weight:
What best describes you:
Sedentary adult
Exercising adult
Competitive athlete
Adult building muscle
Athlete restricting calories
Which of the following best describes your weight loss/gain situation:
I can eat practically anything I want and not gain weight
I can lose or gain just by adjusting my activity level and eating habits
I find it difficult to lose weight
I can gain weight easily and have to watch what I eat
I find it very hard to gain weight
HEALTH AND MEDICAL CONDITIONS
Any other health conditions, concerns, issues I should know about that are not listed above:
Are there any medical conditions that I should be aware of that are not listed above?
What time do you normally wake up?
If you smoke or vape, how many times per day and how many years have you smoked?
If so, how many and what kind do you drink?
FOOD ALLERGIES & GENERAL INFORMATION
Are you allergic to any types or kinds of foods?
Do you have a history of heart disease?
Do you have a history of metabolic disease (thyroid, liver, renal)?
Have you experienced any chest pains?
Have you experienced shortness of breath even during light exercise?
Have you had any problems with dizziness or faintness?
Do you have difficulty in breathing while standing?
Do you suffer from ankle edema (swelling of the ankles)?
Do you have a heart murmur?
Have you experienced accelerated heart bead or heart flutters?
Have you experienced severe pain in the leg muscles while walking?
Do you have a family history of cardiac or pulmonary disease prior to age 55?
Have you been assessed as hypertensive on at least 3 occasions?
What is your average blood pressure?
Please include everything you eat in one 24 hour period. Be sure to include snacks, beverages and water. Also show the approximate amounts:
Make a list of your favorite foods.
Make a list of foods you DISLIKE.
If yes, by whom and what did it consist of?
What were your results?
If yes, what was it and when?
Are you natural or on/used anabolic steroids or on a Testosterone Replacement Plan – TRT)?
If you are on or used anabolic steroids please list your current cycle AND last cycle + duration on your TRT Plan.
If you are on a TRT plan what is your regimen?
Do you prefer to be enhanced (use steroids and other substance) or be natural.
Do you prefer macros or a set plan?
On average, how many steps do you get in a day?
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