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Participant Release and Agreement

 

I, __________________________________, wish to participate in an exercise and training program offered at Power 3 Fitness Coaching and Schwartz Laboratories, LLC and recognize I am a client of the service and not the client of any individual trainer/instructor.  I understand there are inherent risks of injury or death in participating in a program of strenuous exercise and I acknowledge that I assume those risks.  Consequently, I hereby confirm that I have been examined by a physician of my choice and obtained his/her approval for my participation in the Program.  I hereby certify that no change has occurred in my physical condition since the date of such approval was given which might affect my ability to participate in any exercise program.

I agree that Power 3 Fitness Coaching and Schwartz Labs, LLC, it owners, officers, employees, agents, successors and assigns shall not be liable or responsible for any claims, demands, causes of actions, or on account of death, property damage or any injuries to me resulting from my participation in the program (whether at home or a health club, or corporate, commercial, residential or other fitness facility); and I expressly release and discharge Power 3 Fitness Coaching and Schwartz Laboratories, LLC, its owners, officers, employees, agents, successors and assigns, from any and all claims, demands, causes of actions, judgments or the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of my death, property damage or any injury or other damage which may occur in connection with participation in the program (excepting only injury caused by the gross negligence or intentional act of such persons or persons).  This release shall be binding upon my heirs, executors, administrators and assigns.

I understand that during the performance of the program, physical touching and positioning of my body by the trainer may be necessary to assess my muscular and bodily reactions to specific exercises, as well as ensure that I am using proper technique and body alignment.  I expressly consent to the physical contact for the stated reasons above.

 

WAIVER AND RELEASE OF LIABILITY

 

In consideration of the risk of injury while participating in Group X Classes or Personal Training (the Activity), and as consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, and do hereby release and forever discharge Power 3 Fitness Coaching, located at 7227 Montgomery Rd, Cincinnati, Ohio 45236-3942, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from an event related to this Activity.

I AM VOLUNTARILY PARTICIPATING IN THE AFOREMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH TRAVELING TO AND FROM AS WELL AS PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO, PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISFIGUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS' NEGLIGENCE, CONDITIONS RELATED TO TRAVEL, OR THE CONDITION OF THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN OR UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY, INCLUDING TRAVEL TO, FROM AND DURING THIS ACTIVITY.

 

I agree to indemnify and hold harmless Power 3 Fitness Coaching against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If Power 3 Fitness Coaching incurs any of these types of expenses, I agree to reimburse Power 3 Fitness Coaching. I acknowledge that Power 3 Fitness Coaching and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Power 3 Fitness Coaching.  I acknowledge that this Activity may involve a test of a person's physical and mental limits and may carry with it the potential for death, serious injury, and property loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic and actions of others, including but not limited to, participants, volunteers, spectators, coaches, event officials and event monitors, and/or producers of the event.

 

I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS "WAIVER AND RELEASE" AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. I EXPRESSLY AGREE TO RELEASE AND DISCHARGE Power 3 Fitness Coaching AND ALL OF ITS AFFILIATES, MANAGERS, MEMBERS, AGENTS, ATTORNEYS, STAFF, VOLUNTEERS, HEIRS, REPRESENTATIVES, PREDECESSORS, SUCCESSORS AND ASSIGNS, FROM ANY AND ALL CLAIMS OR CAUSES OF ACTION AND I AGREE TO VOLUNTARILY GIVE UP OR WAIVE ANY RIGHT THAT I OTHERWISE HAVE TO BRING A LEGAL ACTION AGAINST Power 3 Fitness Coaching FOR PERSONAL INJURY OR PROPERTY DAMAGE.

 

To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Power 3 Fitness Coaching, its agents, and employees.  In the event that I should require medical care or treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.  In the event that any damage to equipment or facilities occurs as a result of my or my family's willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness. This Agreement was entered into at arm's length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both the Participant and Power 3 Fitness Coaching agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.

 

In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.

 

I hereby certify that I am the parent or guardian of the participant named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Are you (chose one)*

PHYSICIAN'S NAME

PHONE

GOALS

LIMITATIONS

Age

Body Weight

What is your primary goal or reason for contacting Power 3 Fitness Coaching?

Is there a secondary goal?

Do you have a deadline that you'd like to reach these goals by?

What was your weight going into college?

What was your weight 5 years ago?

Physical Activity Assessment 


What do you do for a living?

When at work, are you typically seated, lightly active such as walking around, or doing heavy labor?

How regular is your work schedule? Do you have the same schedule each day or does it vary per day?

Do you work days, afternoons, or nights?

Weights / Resistance 


Do you currently lift weights on a regular basis? (If no, please skip this section)

How many days are you lifting per week?

What current type of training do you do?

Do you lift heavy? high rep? full body? Tell us more.

Any other information we should know?

Cardio / Aerobics 


Do you currently do cardio on a regular basis?

What type of cardio do you do? HIIT, spinning, steady state cardio, walking, running? Please go into detail.

Do you currently attend group fitness classes, or do you prefer to do cardio on your own?

What types of cardio have you done in the past?

Any that you love?

Any that you hate?

Any type that you have always wanted to give a try?

Dietary Assessment 


What type of foods are your favorite?

Do you enjoy crunchy/salty types of foods or are you drawn more to sweets?

How long after eating do you normally feel hungry?

How many meals per day are you normally eating?

Do you know what foods are considered a carbohydrate, protein and fat? Write one example of each:

What are some "unhealthy" foods/drinks that you feel you cannot live without?

Please list any supplements that you're currently taking.

Social Support Assessment 


Do the people around you follow healthy lifestyle habits?

Do your coworkers frequently bring in treats?

When wanting to exercise, is it easy to find a friend to go with you?

Would friends and family support you or sabotage you on this journey to better yourself?

Three-Day Dietary Record

This should be an accurate as possible account of what you've eaten over the next three days. We are not here to judge what you've been eating, this is solely to see what your normal day to day intake is like. Please do not change your eating habits in any way over these three days, this will skew our approach to your program. We know that this seems like a lot of work, but this isn't forever and it's an important part of the process. 

Here is an example: 

Food Item, Quantity, Notes

Day 1: Breakfast 

Oatmeal, 1 Cup, Kroger, quick 1-minute
Hard boiled eggs, 2, Salt, pepper
Daily vitamin, 1 capsule
Orange juice, 4 oz, Tropicana, high pulp

Day 1: Lunch

Pizza, 2 slices, Papa John's veggie lovers
Iced tea, 6 oz, Sweetened with sweet n low

Day 1: Dinner

Angel Hair, 2 cups cooked
Marinara Sauce, half cup, Newman's Own tomato basil
Turkey Meatballs, 2 medium, Homemade with 93/7% fat
Olive Oil, 3 oz
Milk, 8 oz, 2%

Snacks

Movie popcorn, 3 cups, Orville Redenbacher movie theatre popcorn
Iced tea, 12 oz, sweetened with sweet-n-low


Day 1: Breakfast

Day 1: Lunch

Day 1: Dinner

Day 1: Snack

Day 2: Breakfast

Day 2: Lunch

Day 2: Dinner

Day 2: Snack

Day 3: Breakfast

Day 3: Lunch

Day 3: Dinner

Day 3: Snack

When we build your meal plan menu let us know which foods you love! Check your favorites below:

Protein (4-8 ounces)

Chicken Breast
Cod
Salmon
Turkey Breast
Grouper
Tuna
Bison
Flank Steak
Filet Mignon
Sirloin
Tofu
Shrimp
Flounder
Eggs
Lean Ground Turkey
Protein Powder

Carbs (1/2 - 1 cup)

Oatmeal
Sweet Potatoes
Red Potatoes
Golden Potatoes
Brown Rice
White Rice
Quinoa
Black Beans
Pinto Beans
Baked Potato
Cream of Wheat
Grits
Peas
Lentils
Corn
Barley
Whole Grain Pasta

Vitamins and Minerals (1 cup)

Asparagus
Broccoli
Green Beans
Zucchini
Cabbage
Brussel's Sprouts
Spinach
Kale
Peppers
Carrots
Squash
Onions
Leafy Greens
Cauliflower
Tomato
Mushrooms

Fruit (1 cup)

Strawberries
Blueberries
Pears
Raspberries
Blackberries
Melon
Bananas
Mango
Apples
Dates
Grapefruit
Oranges
Plums
Peaches

Fats (2 tablespoons)

Avocado (mu)
Raw Almonds (mu)
Peanuts (up)
Hummus(mu,pu)
Coconut Oil (s)
Olive Oil (mu)
Flax Seed (pu)
Chia Seed (pu)
Pumpkin Seeds (mu)
Sunflower Seeds(PU)
Nut Butter
Coconut Oil (s)

*Please add in anything we missed that you love*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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