Get Started

Please fill out the questionnaire below so that I may contact you. I look forward to speaking with you about your health and fitness and how we might work together to meet our goals.
*Required field

* First Name:
* Last Name:
* E-mail Address:
* Confirm E-mail Address:
* Address Line 1:
Address Line 2:
* City:
* State:
* Zip Code:
* Telephone:
Mobile Phone:
* Best Time to Call:
* Age:
* Sex:       Male      Female

General Health
* Current Height:
* Current Weight:
* Weight 1 year ago:
* How much weight would you like to lose?
* How much weight would you like to gain?
* Do you consider yourself to have a high stress level?       Yes      No
* Is your total cholesterol greater than 200?       Yes      No
* Do you suffer from weak bones and/or joints?       Yes      No
* Do you smoke?       Yes      No
If you smoke, how many packs per day?
* Do you drink alcohol?       Yes      No
If you drink alcohol, how many drinks per week?

Fitness Goals
Please indicate your personal health and fitness goals. Check all that apply:

* Fitness Goals:
Fat Loss
Improve Flexibility
Reduce Stress
Lower risk of disease
Stop Smoking
Rehab Injury
Improve Cardiovascular
     Fitness
 Gain Muscle size
Improve Sports
     Performance
Enhance Health
Reduce Pain
Improve Diet
Feel better
Increase muscle
     strength

Nutrition
* How many meals do you eat per day?
* Do you skip meals?       Yes      No
If you skip meals, check which ones you skip on most days?     Breakfast    Lunch    Dinner
* What time do you eat breakfast?
* What time do you eat lunch?
* What time do you eat dinner?
* Do you eat snacks?       Yes      No
* If you eat snacks, when do you eat them? Check all that apply:
  Between breakfast & lunch
Between lunch & dinner
Between dinner & bedtime
Middle of the night
* How many times per week do you eat fatty foods, fast foods, or fried foods?
* Do you crave sweets or carbohydrates?       Yes      No
* How many servings of fruits and vegetables do you eat daily? A serving equals 1/2 cup of cooked or raw vegetables; 1 cup of leafy vegetables; 1/2 cup of fresh, frozen or cooked
 
List any food allergies you have:
* Are you currently dieting?       Yes      No
* Are you currently or have you ever taken any product to enhance weight loss?       Yes      No

Women's Health
* Are you menopausal?       Yes      No
* Do you suffer from hot flashes?       Yes      No
* Are you pregnant or lactating?       Yes      No