CBS Pre-Assessment Form
Welcome to Chicago Body Shop! This pre-assessment helps us learn more about you, your goals, current habits, movement history and any limitations so we can create a plan that meets you exactly where you are. 
Please take a few minutes and provide honest answers. Your responses are confidential and will guide your initial evaluation. Let's ge to work!
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Email *
Telephone Number *
Full Name *
Date of Birth  *
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Emergency Contact Name  *
Emergency Contact Telephone Number *
Relationship to you? *
Do you have any pre-existing health conditions? If yes, please list: *
Do you have any known hereditary health conditions
 (of parents or siblings)?  (i.e., diabetes, hypertension)
 *
When was your last physical examination? *
Have you had any surgeries? If yes, please list month and year: *
Do you currently have any injuries or chronic pains? If yes, please explain: *
Have you been diagnosed with any mental health conditions? If yes, please list: *
Are you currently taking any medications, prescribed or OTC? If yes, please list: *
Do you have any dietary aversions, allergies or food sensitivities? *
What is your current occupation? *
How active is your job? *
How would you describe your current eating habits in one word? *
How many meals do you eat per day, on average? *
Do you have home cooked meals regularly? *
How often do you snack? What snacks do you typically choose? *
How often do you consume junk food and what kind? *
Do you drink soda? If yes, how often and how much? *
How often do you eat fast food? What are your go-to spot or meals? *
How much water do you drink daily, in ounces? *
Do you currently drink alcohol? *
Do you use marijuana, CBD, THC? *
Do you use any illicit drugs? *
On average, how many hours of sleep do you get per night? Is it quality sleep? *
Are you currently part of a fitness program? *
Do you have a gym membership? *
What are your current health and fitness goals? *
Do you have any specific numeric or performance goals? (e.g, weight loss, muscle gain, race prep) *
Preferred time of day to train (1hr slots)
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Are you training for an upcoming event? If yes, please list event and event date *
Is there anything else we should know to better support your health journey? *
How did you hear about/find us? *
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