CUSE FITNESS/BODY BY PHAEDRA LOOK GREAT NAKED
Name______AGE(DOB)______M/F______
Address______
Phone ______
Email ______CURRENT WT/HT______
Nutrition/Fitness Goals(events/show, time frame, medical/health, academy/military prep)
Online Program ______Onsite Program______written training/nutrition /cardio______
Nutrition Program only _____ (health/event prep/fitness/building)( 4/6/9/12MONTH)
Personal Training only ______(how many days a week interested)(3/4/5 DAYS WEEK)
Personal Training and Nutrition together _____ EVENT PREP/SHOW PREP/POSING ______
List all Medical Problems (injury/surgery dates) Current lab work (attach if within last 6months)____
List all Medications and Supplements (ALL) names dosage and time of day taken
Dietary Concerns or Special Diet followed
LIST ALL TIMES AND DAYS AVAILABLE FOR TRAINING AND/OR NUTRITION APPTS (INCLUDE PREFERRED TIMES AND OTHER TIMES INCLUDE DAYS AND TIME FOR FOLLOW UP AND CHECKIN)
MON / TUE / WED / THUR / FRI / SAT / SUNAM / x
x
PM / x
x
TIME AWAKEN ______TIME SLEEP ______
AMOUNT OF TIME CURRENTLY WORK OUT AND HOW MANY DAYS A WEEK(resistance training, classes ect) :
Time of training am/pm ______
IF DOING AN EVENT GIVE ME EVENT AND TENTATIVE DATES OR GOAL DATES(IF HAVENT CHOSE ONE YET) :
If employed type of work sedetary/active (circle one) weekly hours worked______
Energy level(do you crash middle of day?) slow______moderate______high_____
medical or general referral
if referred by friend/family/doctor (name)______
****ALCOHOL CONSUMPTION (SOCIAL, DAILY(HOW MUCH AND TYPE) WEEKLY (HOW MUCH AND TYPE)
______
315-414-6930
2 DAY NUTRITION CONSUMPTION EVALUATION
Meal 1 time______/ Meal 4 time______Meal 2 time______/ Meal 5 time______
Meal 3 time______/ Meal 5 time______
Cardio time, type of machine,calories burned, resistance training ,wt lifting and/or classes ______
Day 2
Meal 1 time______/ Meal 4 time______Meal 2 time______/ Meal 5 time______
Meal 3 time______/ Meal 5 time______
Cardio (time,machine,calories burned, lifting, type of classes ect.
______
Food list
: Dislikes, allergy, or just won’t eat
______
: Likes must haves or wish to have J
______
Special dietary instructions (gluten free, lactose free ect;
______
PAGES 1-3
DOCUMENT 3 CONSECUTIVE DAYS (INCLUDE ONE OF YOUR MORE DIFFICULT DAYS (WEEKENDS, ECT.)
1. TIME YOU ATE
2. WHAT YOU ATE
3. HOW MUCH YOU ATE (CUPS, SPOONFULS AND OUNCES)
4. INCLUDE ALL FLUID WATER COFFEE, ECT
5. ALL SUPPLEMENT OVER THE COUNTER, PRESCRIBED, AND QUESTIONABLE (YES ENHANCERS)
6. DOCUMENT activity, CARDIO, lifting ,classes ect. THAT IS DONE THE DAYS YOU ARE DOCUMENTING NUTRITION INFORMATION IF NONE PUT NONE
IF YES THE MACHINE, AMOUNT OF TIME, AND CALORIES EXPENDITURE(AKA BURNED).
7. LIKES AND DISLIKES TAKE YOUR TIME AND REALLY THINK YOU WILL BE SURPRISED WHAT YOU DO AND DON’T LIKE …TAKE A FEW DAYS (5)
8. AND ANY SPECIAL NUTRITIONAL NEEDS.. DIABETIC, GLUTEN FREE, LACTOSE INTOLERANT, LOW CHOLESTEROL ECT.
Well come to a new and healthier, non-deprivating lifestyle..
Most important do not change any dietary habits, and be honest…doesn’t help me or yourself if not honest…don’t show me what you think I want to see !!! you can’t fix if you don’t know what is not broken ;).
Supplement and medication sheet