Nutrition Assessment

First Name

Email Address

Phone

Occupation

Height

Last Name

Date of Birth

Address

Weight

What is your goal?

What would you specifically like to change/improve with your physique/figure?

Why is this important to you? Why now?

Do you have a time frame in mind for acheiving your goals?

How committed are you to acheiving your goals within this time frame?

Have you ever participated in a weight loss/gain program? How was your experience

Have you ever worked with a proffessional or personal trainer?

Have you ever participated in a structured resistance training program?

Are you currently working out? If yes, how many times per week or hours per day?

Have you ever taken any multivitamins, weight loss/gain additives, or supplements?

Are you currently doing cardio respiratory excercise? If you, what type?

How many times a day do you usually eat, including snacks?

Do you feel drops of energy throughout the day? If yes, about what time?

At what point in time were you in the best shape of your life?

When did you first start thinking about getting into shape?

What stopped you from taking action in the past?

What do you feel will be different this time?

If you were to start a diet/excercise program, does anyone else need to be involved in making these decisions?

Congratulations! Jason will reach out to you shortly!