Full Name

Email Address

Gender? Gender? Male Female

Has anyone in your immediate family developed heart disease before the age of 60? Has anyone in your immediate family developed heart disease before the age of 60? Yes No

Do any diseases run in your family? Do any diseases run in your family? Yes No

Do you suffer from diabetes, asthma, high or low blood pressure? Do you suffer from diabetes, asthma, high or low blood pressure? Yes No

What do you do for a living?

Do you follow a regular working schedule, do you work days, afternoon or night?

What is the activity level at your job? What is the activity level at your job? None (Seated only) Moderate (Light activity such as walking) High (Jeavy labour, very active)

How often do you travel? How often do you travel? Rarely A few times a year A few times a month Weekly

Your Age

Your Height

Your Weight

Date of Birth

Please list the physical activities that you participate in outside of the gym and work:

What is your goal with your training?

Timeline for achieving your goal Timeline for achieving your goal 8 Weeks 16 Weeks 24 Weeks 32 Weeks

What following goals does best fit n with your goals? What following goals does best fit n with your goals? Improved Health Improved Endurance Increased Strength Increased Muscle Mass

Are you currently exercising regularly (3x a week) Are you currently exercising regularly (3x a week) Yes No

Are you experiencing any stresses or motivational problems? Are you experiencing any stresses or motivational problems? Yes No

Your diet could be best characterized as: Your diet could be best characterized as: Low-fat Low-carb High-Protein Vegetarian Vegan

Are you a smoker Are you a smoker Yes No

If you have any injuries, please list them.

What additional therapies are being undertaken for the given injury?

Please share any other information you feel is important for your consultation