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Assesment Form
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* Indicates required question
Name
*
Your answer
Gender
*
Male
Female
Other
Age
*
Your answer
Body weight
*
Your answer
Height
*
Your answer
Body Fat%
Your answer
Waist circumference
Your answer
BMI
Your answer
Weight Category based on BMI
*
Underweight
Normal
Overweight
Obese
Goal
*
Fat loss
Muscle Gain
Overall Health
Resting Heart Rate
Your answer
Your Blood Pressure
Your answer
Blood cholesterol level
Your answer
Activity Levels
Sedentary
Lightly Active
Moderately Active
Active
Clear selection
You have had
If any of the above statements are true in the above section, consult your physician or
other appropriate health care providers before engaging in exercise. You may need to use
a facility with a medically qualified staff.
a heart attack
heart surgery
cardiac catheterization
coronary angioplasty (PTCA)
pacemaker / implantable
cardiac defibrillator / rhythm disturbance
heart valve disease
heart failure
heart transplantation congenital heart disease Symptoms
You experience chest discomfort with exertion
You experience unreasonable breathlessness
You experience dizziness,
You experience fainting, or blackouts
You experience ankle swelling
have diabetes
take heart medications Other health issues
You have asthma or lung disease
have a burning or cramping sensation in your lower legs
You have musculoskeletal problems
You have concern about the safety of exercise
You take medications
You are pregnant
You Appendectomy
Other:
Smoking Habits
Smoker
Non-Smoker
Quitted Smoking
Clear selection
You have prediabetes
yes
No
Not Sure
Clear selection
RISK CATEGORY BASED ON THE PHYSICAL EXERCISE
Low
Moderate
High
Clear selection
Food practice
*
Vegan (only plant based foods)
Jain (only plant based food excluding root vegetables)
Lacto-Vegetarian (plant based foods and milk products)+eggs
Ovo-Vegetarian (eggs, and plant, no milk products)
Pescatarian (fish, eggs, milk,plant)
Non Vegetarian (all animal and plant based)
How many meals do you usually take food in a day ?
*
Two
Three
Four
five
Do you consume Tea / Coffee ?
*
yes
No
If Yes How many cups per day?
*
Your answer
How do you like your Tea / Coffee ?
*
black
With milk and sugar
only milk
Do you eat any snacks with Tea / Coffee ?
*
Yes
No
If Yes, Wat do you have?
Toast
Biscuit
Samosa
Other:
Clear selection
How frequently do you order from Food Delivery Apps / Eat from outside?
once a week
twice a week
once a month
Other:
Clear selection
What do you usually order when eating outside ?
Your answer
What is the one food item you order when happy / sad ?
Your answer
Do you have any Food Allergies ?
YES
No
Other:
Clear selection
Do you observe any fasts ?
Yes
No
Clear selection
If yes, detail the duration and accepted food items in this period ?
Your answer
Do you drink alcohol ?
Yes
No
Clear selection
If yes, how often?
once a week
twice a week
once a month
social drinking
Other:
Clear selection
What is your preferred choice of drink.
Your answer
What do you usually eat when you drink ?
Your answer
Do you have any prior experience of exercise ?
Yes
No
Clear selection
Which of the following is your preferred form of exercise ?
Gym Workout
running
Walking
Yoga
Other
Clear selection
How many days in a week do you currently workout ?
YES
No
Clear selection
How many days in a week can you work out and for how long ?
YES
No
Clear selection
If we suggest supplements, would you take?
YES
No
Other:
Clear selection
What are your expectations from this program and from your coach?
Your answer
Please mention in detail in case there is anything I have missed, and we should know before starting the plan
Your answer
Preferred language
Your answer
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