Assessment | Mysite

By completing the following 10 minute assessment, I will have the essential information to start getting you ready for your wellness journey.

Full Name

Occupation

Phone

Todays Date

Referred By

Address

Age

Height

Weight

Health History

Current Medications

Current Nurtition Supplements

Women Only: Do you currently have a menstrual cycle?

What would you like to achieve? What would reaching your goals do for you?

Please list any specific previous nutrition/fitness programs you've followed (including any fad diets)

In your opinion, what made you successful? What were some of the barriers to maintaining success?

In what part/s of your body do you feel you carry the majority of your weight/body fat?

Water Intake

Caffeine Intake

Alcohol Intake

Digestion

What do you crave the most?

Salt

Starches

Sugar

Average Stress Level (0 to 10, with 10 being overwhelmed)

How Are You Managing Your Stress?

What time do you go to bed?

What time do you wake up?

Quality of sleep?

Energy Level (1 to 10 with 10 being very energetic)

What activities are you currently participating in?

Current Strength Training Schedule/Routine?

Anything else you would like me to know?