1.Birthday:
February 21, 1978
2. Tell us about your health and fitness goals?
3. Why are these important to you?
4. How committed are you to achieving them.
Life-time
MEDICAL HISTORY 1
5. Please list the bones you have broken in your lifetime: Please describe the incident and the year the injury occurred.
6. Please list the joint injuries and/or surgeries you have endured: Please describe the injury and the year(s) the injury occurred.
7. Please list and briefly describe the car accidents you have been involved in, however minor, and the year.
MEDICAL HISTORY 2
8. Please list all blows to the head that resulted in concussions and the year they occurred.
9. Please list all major surgeries and health incidents and the year they occurred.
10. Are you currently under the care of a physician or health practitioner?
Yes
CURRENT CONDITION
11. Please list any medications you are currently taking.
12. Tell us about past physical/movement activities you have been involved in.
13. Tell us about current physical/movement activities you are involved in.
14. What does your ideal weekly physical/movement schedule look like?
HABITS
15. Tell us about your typical sleep schedule.
When do you rise? 3:00 AM
When do you go to Bed? 10:00 PM
Energy Level in the Morning: 10
Energy Level Midday: 1
Energy Level Night: 5
16. Nutrition: Please share with us on a typical day what your food and beverage consumption looks like.
Optional (and recommended!):
17. Please describe the primary sources of stress in your life:
18. What in your life do you want to change?
19. What is your greatest responsibility? Challenge?
20. What is your life purpose?
