2110 Fitness
New Carbs on the Block intake
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Current Height
Current Weight
Physical Status + Physical Goals and Objectives:
Let us know a little more about you!
In general, what are your goals? (describe all that apply)
Have you tried any diets in the past to change your health, your eating, and/or your body? If so, please tell me what you have tried in the past.
If you answered yes above, what was it about those diets or plans that worked well for you? What didn't work well for you?
Have you made any changes to your habits, workout routine, or diet within the last month? Please describe below.
Understanding Key Motivators
This helps us dive into your habits.
Please list all of your concerns about your health, eating habits, fitness, body, and/or body image.
Out of all of the above concerns, which feel most important or urgent (top 3)?
Lifestyle
A little background info.
Please describe your household (family members, roommates, pets, etc.).
Currently, on a scale of 1 (low) to 10 (high), how much do the people around you support your health and fitness goals?
What is your current workout routine (frequency, duration, type of workout)?
Please detail (type, frequency, and duration) of any non-exercise activity that I should be aware of(e.g., dog walks, yard work, strenuous activity at work, etc.)
Please detail your daily schedule for the week and the weekend.
If your job includes travel, please outline how often you travel and duration of trips.
On a scale of 1 (low) to 10 (high), how do you feel about your schedule, time use, and free time?
What are the top three activities/experiences/situations that bring the most joy to your days/weeks?
Aside from work are their other responsibilities that you have that I should be aware of?
Do you have any food aversions/allergies and/or preferences I should be aware of?
SHREDS
Sleep, Hunger, Energy, Digestion, Stress
On average how many hours per night do you sleep?
On a scale of 1 (low) to 10 (high), how would you rate your sleep quality?
Does your current eating style satisfy your hunger, do your foods make you feel full, or are you always searching for something more after you eat (ie, snacks after a meal)?
On a scale of 1 (low) to 10 (high), how would you rate your hunger on a daily basis?
On a scale of 1 (low) to 10 (high), what is your energy like in...
1
2
3
4
5
6
7
8
9
10
Upon first waking?
Around 10-11am?
After lunch?
Around 3-4pm?
After dinner?
Before bedtime?
Are you currently having good digestion? (This means going to the bathroom daily, minimal bloat etc.)
Do you ever experience gas, constipation, indigestion, or other forms of GI discomfort?
On a scale of 1 (low) to 10 (high), what is your typical stress level on an average day?
What are your 5 favorite activities to manage stress?
Expectations of the Relationship
This helps us help you.
What do you expect from me as your coach?
What are you prepared to do to work toward your goals?
Is there anything else you want me to know about you, your health journey to date, and your goals?
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