Sport Fitness & Physique Assessment Survey

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1. The Basics:
*Your information will be kept strictly confidential.
We will not share, distribute or sell your information in any way.

The Basics: *Your information will be kept strictly confidential. We will not share, distribute or sell your information in any way. First Name:
Address 1:
Address:
City/Town:
State/Province:
ZIP/Postal Code:
Email Address:
Phone Number:

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2. Are you under a doctor's care for any illness, ailment or disease? Please be specific.

Are you under a doctor's care for any illness, ailment or disease? Please be specific.

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3. Please describe what, if any, medication(s) you are currently taking. Please be specific.

Please describe what, if any, medication(s) you are currently taking. Please be specific.

4. What are your health & fitness goals?

What are your health & fitness goals? Release bodyfat

Lower my blood pressure

Gain lean body weight

Get stronger

Get faster

Improve my sleep

Reduce stress

Improve in my sport

Improve my overall health

Reduce my risk of heart attack

Reduce my risk of stroke

Reduce my risk of Alzheimer's, Parkinson's and dementia

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5. What are your top priorities? - Please be specific.
For example:
'I need to lose 12 pounds of fat in 6 weeks.' OR
'I need to reduce my waist measurement 4 inches in 6 weeks.'
OR
'I need to improve my cholesterol 10 points in 4 weeks OR
'I need to lower my blood pressure from 140/90 to 120/70 in 4 weeks.' and so on...

What are your top priorities? - Please be specific. For example: 'I need to lose 12 pounds of fat in 6 weeks.' OR 'I need to reduce my waist measurement 4 inches in 6 weeks.' OR 'I need to improve my cholesterol 10 points in 4 weeks OR 'I need to lower my blood pressure from 140/90 to 120/70 in 4 weeks.' and so on... Highest priority
Second priority
Third priority

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6. Please provide the following measurements:
Upper arm circumference

Please provide the following measurements: Upper arm circumference

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7. Waist circumference (at navel)

Waist circumference (at navel)

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8. Hip circumference (at widest part of butt/hips)

Hip circumference (at widest part of butt/hips)

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9. Upper leg circumference

Upper leg circumference

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10. How much do you weigh?

How much do you weigh?

11. How much would you like to weigh?

How much would you like to weigh?

12. Do you have any food allergies or limitations?

Do you have any food allergies or limitations? Yes

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13. Please list all food allergies or limitations you may have.

Please list all food allergies or limitations you may have.

14. When you set goals, do you tell others what you're working on?

When you set goals, do you tell others what you're working on? Yes

Not usually

Never

Sometimes, it depends

Sport Fitness & Physique Assessment Survey

1. General Information

*1. The Basics:*Your information will be kept strictly confidential.We will not share, distribute or sell your information in any way.

*2. Are you under a doctor's care for any illness, ailment or disease? Please be specific.

*3. Please describe what, if any, medication(s) you are currently taking. Please be specific.

4. What are your health & fitness goals?

*6. Please provide the following measurements:Upper arm circumference

*7. Waist circumference (at navel)

*8. Hip circumference (at widest part of butt/hips)

*9. Upper leg circumference

*10. How much do you weigh?