Lifestyle, Nutrition, & Fitness Assessment
This questionnaire/intake form will help Michele to evaluate your current lifestyle, past experiences, personal goals, struggles, and everything in between. The more truth you share, the netter she can assist and guide you on your journey. Any information collected here is strictly fo the evaluation process and completely confidential. You can rest assured that your information will never be shared and your privacy always comes first.
Email address *
ALL ABOUT YOU
Name (First & Last)
Your answer
Phone number (optional)
Your answer
Date of Birth *
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YYYY
Current Weight (if applicable)
Your answer
Height *
Your answer
BMI (if applicable)
Your answer
I am ready to... (choose one or all that apply) *
Required
LIFESTYLE
How would you describe your current job or daily physical activity levels? Feel free to select and elaborate on any of the options below.  *
Required
What is your day-to-day schedule like? (ex. Early mornings, go to work, gym at lunch, straight home after work to pick up the kids, free time only on weekends etc....) Please list any details which may be important for me to have a better understanding of your lifestyle so I can integrate a program that works best for you.
Your answer
What is your personal body image and feelings when it comes to self esteem, personal growth, and internal feelings? How well do you like/love yourself? Are you open to changing on deeper levels? (I know these are BIG questions. If you are not yet ready to answer it thats fine. Please keep this in mind though as we will circle back during the transformation process.)
Your answer
What are your current body goals? Please describe what you are hoping to achieve with your physical body and lifestyle. Feel free to list/describe attributes you like, dislike, &/or wish to improve...
Your answer
TRAINING & FITNESS
What has been your past history and experience with the gym, classes, sports, athletics, competitions, transformation programs/challenges &/or training (with or without a trainer/coach)?
Your answer
If given instructions on how to workout or based on your past experience, how comfortable are you implementing a program on your own (in or out of the gym)? Please elaborate and share any apprehensions you may have. Many clients are starting with little or no prior experience which is completely fine and doable, but its important to know what level of expertise you are at or how much guidance you may need.
Your answer
Have you ever suffered or are you suffering from any physical injuries as a result of any of the activities mentioned? Please explain.
Your answer
How often do you currently workout/exercise with weights, bands, and/or resistance or any kind such as a reformer machine or other?  *
How often do you participate in cardio of any kind including hiking, walking (Brisk walk, dog/stroller walk etc), jogging/running, boxing or other cardio classes? *
Where will you be working out/implementing your program? Do you have a gym membership (if yes, please list where)? If working out from a home gym or private gym, what equipment do you have available to you? (Cardio equipment, dumbbells & weight amount, exercise bands, balls, machines, etc.)
Your answer
How many days a week & hours a day are you willing to commit to your training program? When answering this, consider realistically what is possible with your current schedule and lifestyle. *
Your answer
Are you currently working out with another trainer. If so, will your trainer be willing to implement a program based on what I put together for you? Are you planning on working out on your own, keeping your current trainer, or both? Are you looking for in-person training with myself or my assistant? *
Your answer
NUTRITION/FOOD EATING HABITS
What is your dietary preference? If you are unsure or would like to explore these options or integrating a new way of eating, please select other. (You will be able to elaborate on your dietary preferences and daily meals in the coming questions)  *
Do you have any food sensitivities you've personally discovered or have been tested for, any dietary restrictions (religious or other), allergies to particular foods or medications? (If yes, please describe/list in detail)
Your answer
Please provide a “true to life” example of what you may eat during any given day. Please include as much detail as possible such as: How many times a day do you eat meals &/or snacks? Please list out meals and snacks from morning till night and also note any special information you might want me to know such as, “I usually don’t eat between 1-4 because I am busy with _____.” OR “At night I tend to eat______" , OR “ I eat out/order in which is usually _____”, etc... Please be as detailed as possible.Think about: What you eat? Servings? Time of Day? Time gaps between meals? Water or beverages?
Your answer
How often do you eat out or order food from restaurants? If more than 3 times a week, please list the places you most often eat at or order from and for which meals.
Your answer
If directed with specifics as to what to eat & how much, are you able to cook/prepare your own meals? If not, will you be ordering from a food service/delivery company? (If so which one?) Please describe.
Your answer
Please list FOODS YOU LOVE & would like to have in your meal program.
Your answer
Please list foods you dislike or DO NOT WANT to have on your meal program or can't have (feel free to elaborate).
Your answer
Please describe foods that you tend to “cheat” most with or foods/meals that you tend to crave or that would be considered your “weakness”. Also, do you crave more of sweets, salty food s, spicy, savory, all of the above?
Your answer
Please list & describe in detail any additional information you feel may be vital to the success of your program that you would like for me to know. If you know there are issues or setbacks you’ve experienced in the past while trying to complete a program or something similar, please give me as much information regarding that as possible so I can help you overcome these obstacles. (Emotional and Mental wellbeing is most important in this process, so please feel free to share anything- this is completely confidential and for coaching purposes only. Illness, eating disorders, personal traumas can and should be shared here as well if you are comfortable and if you haven't already.)
Your answer
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