Name
*
First Name
Last Name
Phone
(###)
###
####
Email Address
*
Date of Birth
*
What is your occupation?
*
Does your job require to frequently travel by car or plane? if yes, how often?
Rank your average daily stress level (1=very low 10=very high)?
How many hours do you regularly sleep at night?
Do you smoke or vape nicotine?
Yes
No
Please share any current or past medical conditions or injuries?
Are you currently taking any medications? If so, please list.
Please describe your exercise history, include any sports or activities.
Are you currently physically active?
Yes
No
Do you have experience in strength training? ( e.g. free weights or machines)
Do you have experience in cardio training? (e.g. classes, running, biking, elliptical)
What are your motivations for coming to Rebel Health NW? What would you like to accomplish? (e.g. fat loss, increased strength, muscle gain, performance)
What are your short term goals (3-6 months) and long term goals (6 months and beyond)
Where do you exercise now?
How often would you like to meet for private training sessions per week and which days and times are best for you?(provide days/times options)
Is there any additional information you would like to share prior to your starting a personal fitness program?
On a scale of 1-10 (10 being extremely healthful), how do you rate your diet?
10
9
8
7
6
5
4
3
2
1
Do you consider your meals to be balanced?
Yes
No
Mostly
Could use improvement
Please list any vitamins, minerals or supplements you take.
How many servings of vegetables do you eat each day? (1 serving = 1 cup broccoli)
1-2
3-4
5 or more
How many servings of fruit do you eat each day? (1 serving = 1 apple)
1-2
3-4
5 or more
Approximately, how many 8oz glasses of water do you drink a day?
Please describe any current dietary restrictions or food allergies that you may have.
Do you generally cook your own meals or eat out?
List the top 5 foods you eat most often:
Do you have good energy levels?
Yes
No
Inconsistent
Do you have any food cravings? If so, please describe:
Do you experience digestive issues such as heartburn, gas, bloating, pain?
Do you drink alcohol and if so, how many drinks do you have a week?
How do you cope with stress?
Do you tend to eat MORE or LESS when stressed?
Do you ever eat for emotional reasons?
What are the 3 things you need to work on as far as nutrition is concerned?
Please describe any other digestive issues or concerns:
How did you hear about Rebel Health NW?
Online Search
A Friend or Relative
Social Media- Facebook, Google +, etc.
Flyer/Postcard/Business card
Speaking Engagement/Workshop
Lead Generation Service- Yelp, Thumbtack, Angie's List, etc.
