Initial Consultation – fit4ulife.com

Name *

First

Last

Phone *

Email *

What is your Age? *

What is your Weight? *

What is your Height? *

What is your Occupation? *

Do you have/had any of the following health issues of which I should be aware?

Let's help facilitate your journey to better health. Please provide me a little more detailed information:

Do you have any food allergies? *

Please list food allergies:

Are you currenty on any medications (outside of vitamins and supplements)? *

Please list medications:

What have your past experiences with weight loss or gain been?

What forms of exercise have you practiced in the past month? *

	I haven't in the past month	< 4x a month	4 – 10x a month	10 – 20x a month	> 20x a month
Aerobic (cardio)	I haven't in the past monthAerobic (cardio) I haven't in the past month	< 4x a monthAerobic (cardio) < 4x a month	4 – 10x a monthAerobic (cardio) 4 – 10x a month	10 – 20x a monthAerobic (cardio) 10 – 20x a month	> 20x a monthAerobic (cardio) > 20x a month
Balance Training (Yoga, Tai Chi, Pilates, etc.)	I haven't in the past monthBalance Training (Yoga, Tai Chi, Pilates, etc.) I haven't in the past month	< 4x a monthBalance Training (Yoga, Tai Chi, Pilates, etc.) < 4x a month	4 – 10x a monthBalance Training (Yoga, Tai Chi, Pilates, etc.) 4 – 10x a month	10 – 20x a monthBalance Training (Yoga, Tai Chi, Pilates, etc.) 10 – 20x a month	> 20x a monthBalance Training (Yoga, Tai Chi, Pilates, etc.) > 20x a month
Endurance (increasing periods of time of activity)	I haven't in the past monthEndurance (increasing periods of time of activity) I haven't in the past month	< 4x a monthEndurance (increasing periods of time of activity) < 4x a month	4 – 10x a monthEndurance (increasing periods of time of activity) 4 – 10x a month	10 – 20x a monthEndurance (increasing periods of time of activity) 10 – 20x a month	> 20x a monthEndurance (increasing periods of time of activity) > 20x a month
Flexibility (Yoga, Tai Chi, etc.)	I haven't in the past monthFlexibility (Yoga, Tai Chi, etc.) I haven't in the past month	< 4x a monthFlexibility (Yoga, Tai Chi, etc.) < 4x a month	4 – 10x a monthFlexibility (Yoga, Tai Chi, etc.) 4 – 10x a month	10 – 20x a monthFlexibility (Yoga, Tai Chi, etc.) 10 – 20x a month	> 20x a monthFlexibility (Yoga, Tai Chi, etc.) > 20x a month
Strength Building (body/weight lifting, Pilates, anything building muscle/bone strength)	I haven't in the past monthStrength Building (body/weight lifting, Pilates, anything building muscle/bone strength) I haven't in the past month	< 4x a monthStrength Building (body/weight lifting, Pilates, anything building muscle/bone strength) < 4x a month	4 – 10x a monthStrength Building (body/weight lifting, Pilates, anything building muscle/bone strength) 4 – 10x a month	10 – 20x a monthStrength Building (body/weight lifting, Pilates, anything building muscle/bone strength) 10 – 20x a month	> 20x a monthStrength Building (body/weight lifting, Pilates, anything building muscle/bone strength) > 20x a month

Overall, At what intensity have you been exercising in the past month? *

Do you experience any pain when exercising? *

Please tell me more about your pain:

Please tell me on average, how many times do you eat in a day? *

What foods do you prefer to eat on a daily basis?

What are your favorite indulgence foods? (You seldom have it, but it's a treat when you do.)

On average, how many hours of sleep do you get a night? *

How much stress are you currently experiencing? *

	Very Low	Low to Moderate	Moderate	High	Extremely High
My Stress Level	Very LowMy Stress Level Very Low	Low to ModerateMy Stress Level Low to Moderate	ModerateMy Stress Level Moderate	HighMy Stress Level High	Extremely HighMy Stress Level Extremely High

If you chose moderate or higher, what are the main contributors to your current stress level?

What are your goals? *