Free Health Assessment

Complete the following form as truthfully as possible to provide us with information about your current habits and general feeling about health and fitness.

Phone

Age*

Height*

Weight*

Body Fat Percentage

if known

Daily Food & Beverage Intake*

Please share your typical daily food intake. Be very specific and complete. Include the time and what meals, snacks and beverages were consumed. Include any other items you eat such as candy, gum, etc.

How many meals do you like to eat in a day?*

What are your current exercise habits?*

Activity Level*

Please rate your daily activity level on a scale of 1-10 (not including your time at the gym). 1 being sitting at a desk and 10 being on your feet all day like a nurse or waitress.

Please enter a number from 1 to 10.

Other*

Medications & Supplements*

Please any medications or supplements you are currently taking, if any. Include over the counter medications like ibuprofen.

Please describe

If "Other" please describe.

How much do you drink?*

How many hours do you sleep?*

How many times a week or month do you eat out?*

Eating Habits*

Describe changes, if any, that you have made to your eating habits in the past?

Fill in the blanks...

To lose weight I need to eat ...*

To lose weight I need to workout ...*

Rate the following questions using 1 as the lowest and 10 as the highest.

Rate how important changing your current health status is to you?*

Please enter a number from 1 to 10.

Rate how confident you are to make this change at this time.*

Please enter a number from 1 to 10.

Barriers*

What barriers, if any, stand in the way of you achieving your nutritional/health goals?

Expectations*

What are your expectations after completing 12 weeks and how do you define success?

How did you hear about us?*

Additional Information

Any additional information you'd like to share?

Number

Email

This field is for validation purposes and should be left unchanged.