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Your lifestyle 

Select one of the following

Important Questions About Your Health History If you answer "yes" to any of these questions, please provide details such as date of occurrence, frequency, intensity, amount, etc

1. Do you suffer from back pain?
2. Are you sensitive to touch/pressure in any area?
3. Do you have tension, numbness or pain in a specific area?
4. Do you experience frequent headaches?
5. Are you pregnant?
6. Have you ever been pregnant
7. Do you have high blood pressure?
8. Do you smoke or have you smoked in the past?
9. Do you have difficulty sleeping?
10. Have you ever broken any bones?
11. Do you experience stiff, swollen or painful joints?
12. Have you ever had surgery?

Your Exercise Status 

Your Nutrition & Metabolism

1. Do you count or track calories?

You mental approach to physical activity 

Would weekly/ bi weekly check-ins help you stay motivated?
Have you ever suffer from mental health?

Your Final Thoughts 

Describe what you truly desire from completing this program. What do you truly desire? Out of your fitness? Out of life? What do you want your body to look like in 1 year? 5 years? In other words, why are you sitting here, taking valuable minutes out of your life to complete this form? What are your specific goals or objectives? Be as honest and specific as possible, describing your dream body, lifestyle, or health. Pour yourself onto the page. Include anything that you feel would be helpful that you haven’t yet had a chance to express. All your responses remain completely confidential!

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