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New Client Questionnaire

Today's Date: March 29, 2020

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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