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BASIC INFO

First Name

Last Name

Today’s Date

Email Address

Mobile Phone

Biological Gender

Female

Male

Street Address 1

Street Address 2

City

State

Zip Code

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IDENTIFY YOUR GOAL

If we don’t know where we are trying to go, how will we know how to get there? The answer is “we won’t.” This is why every successful program must begin with understanding the goal. Goals may include:

BODY COMPOSITION GOAL: This may include a desired body fat percentage, muscle mass increase, achievement of the desired dress size, goal weight, etc.
HEALTH GOAL: Such as lowering cholesterol, lowering blood pressure, reducing anxiety, improving energy levels, regulating digestion, sleeping through the night, etc.
PERFORMANCE GOAL: This could be setting a PR in a race, improving speed, vertical jump, endurance, one rep max, ability to recover, for a sport, etc.

Before we go any further, take a moment to list your short-term (1 month), medium-term (3-6 months), and long-term (6+ months) goals.

1 Month Goal

3-6 Month Goal

6+ Month Goal

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DETERMINE YOUR SUCCESS BLOCKING FACTORS

Before you embark on this journey, it is important for you to understand how willing you are to make changes to your nutritional habits. The results of this form will help us understand how to proceed with your training and nutritional programming. We must determine potential success-blocking factors, including hormonal imbalance, readiness to change, your current kitchen environment, constitutional factors, and toxicity symptoms, to determine the next best steps toward your goal.

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YOUR CURRENT DIET AND EATING PATTERNS

Please select ‘how often you use/consume’ and the ‘level you feel’ for the following areas.

Alcohol

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Artificial Sweeteners

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Candy / Sweets

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Carbonated Beverages

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Chewing Tobacco

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Cigarettes

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Cigars / Pipes

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Coffee

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Fast Food

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Fried Foods

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Lunch Meats / Hot Dogs

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Margarine

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Milk / Dairy Products

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Non-Herbal Tea

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Refined Flour / Baked Goods

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Refined Sugar

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Vitamins / Minerals

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Distilled Water

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Tap Water

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Well Water

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

Diet

0 = Never

1 = Weekly 2-3x

2 = Weekly 3-6x

3 = Daily

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YOUR LIFESTYLE AND ACTIVITY LEVELS

How often do you Exercise?

How often have you Changed Jobs?

How often have you been Divorced?

How often have you worked a 60+ Hour Work Week?

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YOUR CURRENT MEDICATIONS

In the past month, have you taken Antacids?

Yes

No

In the past month, have you taken Antibiotics?

Yes

No

In the past month, have you taken Anticonvulsants?

Yes

No

In the past month, have you taken Antifungals?

Yes

No

In the past month, have you taken Aspirin / Ibuprofin?

Yes

No

In the past month, have you taken Asthma Inhalers?

Yes

No

In the past month, have you taken Beta Blockers?

Yes

No

In the past month, have you taken Chemotherapy?

Yes

No

In the past month, have you taken Cortisone?

Yes

No

In the past month, have you taken Diabetic Medications?

Yes

No

In the past month, have you taken Diuretics?

Yes

No

In the past month, have you taken Estrogen / Progesterone?

Yes

No

In the past month, have you taken Heart Medications?

Yes

No

In the past month, have you taken High Blood Pressure Medication?

Yes

No

In the past month, have you taken Hormone Therapy?

Yes

No

In the past month, have you taken Laxatives?

Yes

No

In the past month, have you taken Ulcer Medications?

Yes

No

In the past month, have you taken Radiation Exposure?

Yes

No

In the past month, have you taken Recreational Drugs?

Yes

No

In the past month, have you taken Thyroid Medication?

Yes

No

In the past month, have you taken Oral / Implant Contraceptives?

Yes

No

In the past month, have you taken Relaxants / Sleeping Pills?

Yes

No

In the past month, have you taken Tylenol / Acetominophen?

Yes

No

In the past month, have you taken Insulin?

Yes

No

How Hungry are you daily?

1 = Not • 10 = Extremely

How much Energy do you have daily?

1 = None • 10 = Plenty

What is your general Temperature (feeling) daily?

1 = Cold • 10 = Hot

How many Cravings do you have daily?

1 = None • 10 = Plenty

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YOUR CONDITIONS

GROUP 1: Select each condition you experience.

GROUP 2: Select each condition you experience.

GROUP 3: Select each condition you experience.

GROUP 4: Select each condition you experience.

GROUP 5: Select each condition you experience.

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DIGESTION

How often and what level do you feel Nausea?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Loose Stool?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Constipation?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Bloating?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Heartburn?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Belching / Passing Gas?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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EMOTIONS

How often and what level do you feel Emotions?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Depression?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Irritability / Frustration?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Fear?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Anxiety / Nervousness?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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EARS

How often and what level do you feel Itchy Ears?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Ringing in the Ears?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Earache / Infection / Drainage?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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ENERGY

How often and what level do you feel Fatigue?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

Restlessness

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Hyperactivity?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Laziness / Indifference?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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HEAD

How often and what level do you feel Headaches?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Difficulty Sleeping?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Dizziness?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Fainting?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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EYES

How often and what level do you feel Watery / Itchy Eyes?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Swollen / Red Eyes?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Dark Circles Under the Eyes?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Blurred / Tunnel Vision?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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JOINTS & MUSCLES

How often and what level do you feel Joint Pain / Aches?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Muscle Pain / Aches?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Arthritis?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Joint Popping / Clicking?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Morning Muscle Stiffness?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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SINUS & NOSE

How often and what level do you feel Sinus Congestion / Mucus?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Stuffy Nose?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Allergies?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Sneezing?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Sinus Problems?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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LUNGS

How often and what level do you feel Chest Congestion?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Asthma?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Bronchitis?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Shortness of Breath?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Difficulty Breathing?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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MIND

How often and what level do you feel Poor Memory?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Foggy Head?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Difficulty Remembering Thoughts of Words?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Poor Coordination?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Stuttering / Stammering?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Poor Concentration?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Difficulty Making Decisions?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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WEIGHT

How often and what level do you feel Binge Eating / Drinking?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Food Cravings?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Excessive Weight Gain?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Nervous Eating?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Water Retention?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Difficulty Gaining Weight?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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MOUTH & THROAT

How often and what level do you feel Gagging Easily?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Phlegm in Throat?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Difficulty Swallowing?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Swollen Tongue / Throat?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Canker Sores?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Horse Voice?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Sort Throat?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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SKIN

How often and what level do you feel Acne?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Dry Skin / Rashes?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Hair Loss?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Facial Flushing / Hot Flashes?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Excessive Sweating?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

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OTHER

How often and what level do you feel Genital Itching?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Frequent Cold / Illness?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe

How often and what level do you feel Frequent Urination?

0 = Never

1 = Occasionally / Mild

2 = Occasionally / Severe

3 = Frequently / Mild

4 = Frequently / Severe