LIFESTYLE & HEALTH HISTORY Today's Date * MM DD YYYY Contact Information Name * First Name Last Name Date of Birth * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Personal Cell Phone * (###) ### #### Personal Email * Emergency Contact Name * Relationship * Cell Phone * (###) ### #### Occupational What is your current occupation? * Does your occupation require extended periods of sitting? * Yes No Does your occupation require repetitive movements? * Yes No If you answered yes to the above, please explain. Exercise/Activity What exercise and recreational activities do you currently take part in? * e.g., running, strength training, group exercise, golfing, hiking, pickleball, walking my dog. How many days per week do you get at least 60 minutes of moderate intensity exercise? * 1 2 3 4 5 6 7 Diet/Lifestyle Do you eat a whole foods diet? * Yes, I eat mainly or only whole foods. I eat a mix of whole and processed foods. I eat the Standard American Diet (mostly processed foods) I need help, I am a carb/sugar junkie! Do you smoke cigarettes? * Yes, I smoke cigarettes. I occasionally smoke cigarettes. No, I don't smoke cigarettes. Do you drink alcohol? * Yes, I drink alcohol daily. Yes, I have a few drinks throughout the week. I rarely drink alcohol or I don't drink. Are you chronically stressed? * Yes, I am always stressed. I am moderately stressed. I am stressed occasionally. I am stress-free baby! Do you get quality sleep each night? * Yes, I get 8-9 hours of sleep a night. I get around 7 hours of good sleep. I might get 6 hours of sleep if I'm lucky. No, I get poor sleep. What is most important to you? Fat Loss, Muscle/Strength, or Health Improvement/Longevity? Fat Loss Muscle / Strength Health Improvement / Longevity What is SECOND most important to you? Fat Loss, Muscle/Strength, or Health Improvement / Longevity? * Fat Loss Muscle / Strength Health Improvement / Longevity Medical Have you ever had any pain or injuries? (ankle, knee, hip, back, shoulder, etc.) * Yes No If you answered yes to the above, please explain. Have you ever had any surgeries? * Yes No If you answered yes to the above, please explain. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure) or diabetes? * Yes No If you answered yes to the above, please explain. Are you currently taking medication? * Yes No If you answered yes to the above, please list your medications and describe their use. Is there anything you would like to share that you feel I should know? Thank you! I’m so excited to meet you! will be in touch within 24-48 hours to schedule our consultation. Enjoy your day!
