Client Questionnaire

Please fill out this questionnaire as completely as possible. The better we get to know you, the better a tailored plan we can create for you.

Your Name *
Your Name
Describe what you eat in a typical day. Include any snacks, and if you have any particular habits (ex. using sauces/dips, snacking late at night, binge-eating, skipping meals, meal prepping, eating out, etc.)
Describe your overall physique (ex. areas that bother you the most, areas you are happiest with, any injuries or reasons you might not be able to do certain exercises).
How Often Do You Eat? *
How many times per day do you eat (including snacks)?
What time of the day do you/can you workout?
How much experience do you have? How comfortable do you feel with weight training?
Do You Drink *
Check all that apply
Meals Per Day *
What is the maximum number of meals you want to have during the day (a protein shake with fruit and nuts can count as a meal)?
Do You Smoke? *
What are you weaknesses with diet? (Snacking? Late night eating? Measuring? Meal-prepping? Disliking "healthy" food? Sweets/chocolate? Salty foods? Other?)
How many days can you commit 1 hour to working out at the gym? (If must be 45 min or 30 min, please specify)
Select which program you are interested in.
Check all the ALLERGIES you have: *
Are there any ingredients/foods that you so not want eat? (Please tell me WHY: if it is because you do not like the taste or texture, or because of your beliefs). Are there any foods/ingredients you LOVE to eat?
Check any protein sources you WILL NOT eat *
Failure to check off an item may result in the inclusion of that food in your program. If you DO NOT explicitly exclude it here, your program cannot be revised.
Check any carb sources you WILL NOT eat *
Failure to check off an item may result in the inclusion of that food in your program. If you DO NOT explicitly exclude it here, your program cannot be revised.
Check any Fruits and Vegetables you WILL NOT eat *
Failure to check off an item may result in the inclusion of that food in your program. If you DO NOT explicitly exclude it here, your program cannot be revised.
Check any fats you WILL NOT EAT *
Failure to check off an item may result in the inclusion of that food in your program. If you DO NOT explicitly exclude it here, your program cannot be revised.
Exercise Challenges *
Which exercises can you not perform (because of injury)?
Are you
If your answer is YES to any of these, THIS PROGRAM IS NOT FOR YOU. We recommend seeking guided medical support from a qualified medical specialist. Please contact the national eating disorder association at nationaleatingdisorders.org.
Please review your answers for accuracy. Any dietary or training needs NOT mentioned will NOT be accounted for in your program unless they are expressly written. * ATTENTION* If you have an underlying condition, such as diabetes or PCOS, BE SURE TO MENTION THIS HERE. If you do not, type "None" in this section.
Please provide a link to at least one current photo of your body (front) in a bikini, or sports bra and shorts. You may choose to share 3 photos (front, side, & back). We suggest uploading to dropbox, icloud, or onedrive, and sharing the photo's link).
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