Skip to content
Fitness and nutritionInventory
Current Body Fat Percentage (If Known)
How many months did you sign up for?
Which plan did you sign up for?
Exercise and Nutrition
Do you have a gym membership
Minor Goals (any areas you want to grow in outside of fitness/nutrition.)
Number of Days per Week you can Work Out
Times of Workouts in the Day
Time Allowed for Workouts
Previous Involvement/Experience with Fitness/Sports: how is your knowledge of exercise forms, do you know what a drop set is or super set?
How much (if any) are you working out now and how much cardio (minutes and type)?
Do you have a phone or watch that tracks your steps? How many do you average/day?
Do you have something that tracks your daily steps? If yes, how many steps do you usually average?
Typical stress levels, 1 being hardly any, 10 being AHH!
What is your morning resting heart rate? (use your index and middle finger on your wrist to find your pulse. count how many beats during 30 seconds and multiply by 2)
Medical History Red Flags
When is the last time you have had a full/partial blood panel done? Any concerns?
Stomach Acid Test.... 1.First thing in the morning (before eating or drinking) mix 1/4 teaspoon of baking soda in 4 ounces of cold water 2. Drink the baking soda solution.Set a timer and see how long it takes you to burp. If you have not burped within five minutes, stop timing. 3. Indicate below how long it took you to burp or not at all.
Steak (top round or sirloin)
Lean Ground Beef
Lean Ground Chicken
Plant based protein
Preferred Fat Sources
All Bran Cereal/ Cheerios
Cream of rice
Cream of Wheat
Whole Wheat Pasta
Bagels/Whole Grain Bread
Healthy Foods You Hate
Do you have a Sam's/Costco Membership?
Foods That You Eat as Cheats
Describe a typical day of eating (the more detail the better)
Do you use a protein powder If so, what brand?
Do you use any other supplements? if so which ones?
Are you on any medications? which ones?
Estimated Daily Water Intake
Do you drink alcohol. If so, how frequent?
Do you smoke?
Job/Other Activity Outside of Work that Affects Daily Caloric Expenditure
What state/country do you live in?
Are you ok with me using progress pictures for marketing/social media?
How much accountability/check in do you need? 1 being once a week check-ins, 10 being daily check-ins
Any other information you think I should know regarding your body?
REQUIRED TO START: 3 Pictures: Front, Back, and Side (standing relaxed) Please EMAIL these. I need to be able to see your stomach, arms, legs, shoulders, back, legs and chest (for guys). If this is an issue, logistically or mentally, please let me know. Following this step I may have some follow up questions and then typically it is 7 business days to write the plan! It may sometimes take longer depending on schedule. I will keep you updated.
Purpose and Explanation of Service I understand that the purpose of the exercise and nutrition program is to develop and maintain cardiorespiratory fitness, body composition, flexibility, muscular strength, healthy eating habits, and endurance. A specific exercise and nutrition plan will be given to me, based on my needs and abilities. All exercise prescription components will comply with proper exercise program protocols. The programs include, but are not limited to aerobic exercise, flexibility training, and strength training. All programs are designed to place a gradually increasing workload on the body in order to improve overall fitness. Risks I understand, and have been informed, that there exists the possibility of adverse changes when engaging in a physical activity program and ingesting particular foods, supplements, or liquids. I have been informed that these changes could include abnormal blood pressure, fainting, disorders of heart rhythm, stroke and very rare instances of heart attack or even death. I have been told that every effort will be made to minimize these occurrences by proper screening and by precautions and observations taken during the prescribed plans and based on the information provided herein. I understand that there is a risk of injury, heart attack, or even death as a result of my participation in an exercise and/or nutrition program, but knowing those risks, it is my desire to partake in the recommended plans. Benefits I understand that participation in an exercise program has many health related benefits. These may include improvements in body composition, range of motion, musculoskeletal strength & endurance, and cardiorespiratory efficiency. Furthermore regular exercise and proper nutrition can improve blood pressure and lipid profile, metabolic function, and decreases the risk of cardiovascular disease. Physiological Experience I have been informed that during my participation in the exercise program I will be asked to complete physical activities that may elicit physiological responses/symptoms that include but not limited to the following: elevated heart rate, elevated blood pressure, sweating, fatigue, increased respiration, muscle soreness, cramping, nausea. Confidentiality and Use of Information I have been informed that the information obtained in this exercise program will be treated as privileged and confidential and will consequently not be released or revealed to any person without my express written consent. Any other information obtained, however, will be used only by the program staff to evaluate my exercise and health status as needed. Inquiries and Freedom of Consent I have been given an opportunity to ask questions about the exercise program. I further understand that there are also other remote health risks. Despite the fact that a complete accounting of all these remote risks has not been provided to me, I still desire to proceed with the exercise program. I acknowledge that I have read this document in its entirety or that it has been read to me if I have been unable to read same. I consent to the rendition of all services and procedures as explained herein by all program personnel.
I acknowledge that I have read this document in its entirety or that it has been read to me if I have been unable to read. I consent to the rendition of all services and procedures as explained herein by all program personnel.