Initial Assessment
Please complete this form as detailed as you can. This will better help me form a program that fits your needs!
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Email *
First Name *
Last Name *
Gender
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Age
Weight (in lbs)
Height (in ft/in)
What does a regular day look like for you? Please describe.
In general, what are your goals? Check all that apply.
Out of all the above concerns, which ones feel most important/urgent?
Why?
What do you expect from a workout program?
Do you understand energy balance (calories in vs calories out)? If yes, please briefly break down what it means in your own words.
How, specifically, would you like your habits, your health, your eating, and/or your body be different?
Until now, what has blocked you or held you back from changing these things? (if anything)
Do you have experience tracking calories?
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Are you regularly active in sports and/or exercise? If so, approximately how many hours per week?
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Do you know how to perform the following exercises? Check the box for "yes":
What equipment is available to you? Check the box for "yes":
How many days a week are you able to train?
How much time are you able to train each day?
Approximately how many hours a week do you do other types of physical activity? (ex. housework, walking to work/school, home repairs, moving around work, gardening, etc.)
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Do you have any injuries, physical conditions, disabilities, pain or illness?
List any additional therapies/treatments for any injuries or conditions.
Right now, are you taking any medications, either over-the-counter or prescription, or supplements?
Are you pregnant or nursing?
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What do you do for a living?
Does your job entail shift work?
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In an average week, how many hours do you spend in paid employment?
In an average week, how many hours do you spend at school or doing school work?
In an average week, how many hours do you spend taking care of others? (children, person with a disability, parents, etc)
In an average week, how many hours do you spend doing other unpaid work? (commuting, housework, errands, volunteering)
On a scale of 1-10, how do you feel about your schedule, time use, and overall busy-ness?
My life is panicked and insane
My life is perfectly calm and relaxed
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Given all the demands of your life, what is your typical stress level on an average day?
No stress
Extremely stressed
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On average, how many hours per night do you sleep?
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How do you normally cope with your stress?
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