Age: Date of Birth: (m/d/year):

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1 Name: Basic Information: Gender: Height: Date: Age: Date of Birth: (m/d/year): Weight: Body Measurements: Neck Girth: Chest Girth: Upper Arm Girth: Waist Girth: Hip Girth: Shoulder Girth: Thigh Girth: Calf Girth: Please see the attached sheets for instructions. Please take the following photos: Front Side Left Side Right Side Back Side Notes: Men: wear a pair of shorts, Women: swimsuit or sports bra and shorts Record camera used, distance away from camera and any lighting notes. Progress photos will need to be taken under the same conditions. Goals: Please list in the order of importance, 1 being the most important, 8 being the least important Improved health Improved Endurance Increased Strength Sport Specific Increased Muscle Mass Fat Loss Name Sport Increased Power Weight Gain Do you have a specific date in mind to reach a certain goal? If yes, please explain. What is more important to you? Fast progress that is difficult to maintain Maintainable progress that may be slower

2 Exercise Information: Are you currently exercising? If yes, how many times per week? How long have you been exercising without a break of more than two weeks? List how many times a week you perform the following type of exercise and the time spent: High Intensity Low Intensity Strength CrossFit Sport Specific If you are not currently exercising, have you ever been consistent with a training plan? If yes, what type of exercise was it? How long ago was it? How long did it last? Medical and Health Information: List any diagnosed health conditions: List any medications you are currently taking: List any current therapy/treatments for the given conditions: List any injuries: List any current therapy/treatment for the injury(s):

3 Lifestyle Information: What do you do for a living? What is your activity level at your job? Seated Work (Desk Job) Moderate (walking, light activity) High (heavy labor, very physical) Does your job involve shift work? If you follow a more consistent schedule, do you work: days afternoons nights Are you a primary caregiver for children, individuals with a disability, or an elderly person? How often do you travel? rarely yearly (4 or more/year) monthly (1-3x/mos) weekly Please list any physical activities that aren t included in your work or gym routine:

4 Please fill out the attached Work Day Schedule Chart & Day Off Schedule Chart How much money do you spend on groceries per month? (use your last two grocery trips as a reference) How many times a week do you shop for groceries? How many meals do you eat in restaurants/fast food places per week? How much money do you spend on supplements per month? Please list any known food allergies: Please list any known food sensitivities (foods that cause bloating, congestions, etc.): Please list any current nutritional supplements (as well as the doses):

5 Work Day Schedule Please fill out the schedule with your most normal work day schedule, listing the time you wake up, work, breaks, eat, workout, go to sleep etc. Time(am) Activity Time (pm) Activity

6 Day Off Schedule Please fill out the schedule with your most normal day off work schedule, listing the time you wake up, work, breaks, eat, workout, go to sleep etc. Time(am) Activity Time (pm) Activity

7 Miscellaneous Information: If there is any other information that you feel may be relevant? What is your most frequent health, nutrition, performance or physique complaint? Anything else you d like to add? Please fill out the attached three-day diet record.

8 Initial Assessment Name: Date: Rate the following on a scale of 1-10 Mood Appetite 1 = no appetite 10 = extremely hungry Sleep Quality 1 = poor sleep 10 = great sleep Tiredness 1 = Not tired 10 = extremely tired Score AM: PM: EVENING: AM: PM: EVENING: AM: PM: EVENING: Willingness to Train 1 = not willing 10 = very excited to train AM: PM: EVENING: Record Resting Heart Rate (beats per minute): Take heart rate first thing in the morning from a seated position. Count the number of beats in 60 seconds, using your index finger placed on your carotid artery or your radial artery. (neck/wrist).

9 Hunger Awareness Worksheet Name: Date: Record how hungry you are before you eat and how hungry you are when you re done. Describe physical and emotional feelings, particularly how your stomach feels. Example: 1 = extremely hungry, 4 = neutral, 7 = stuffed/too full/feeling sick Date/Time Oct 1 9am Before: 3 After: 5 Notes: Hungry when I work up, made breakfast. Felt good after I ate. Oct 1 3pm Before: 1 After: 7 Notes: I worked through lunch. Starving. Ate too much, too fast. Stomach hurts. Oct 1 6:30pm Date/Time Before: 2 After: 6 Notes: Ate supper watching tv. Didn t feel full until it was too late. I feel bloated. Notes Before: After: Notes: Before: After: Notes: Before: After: Notes:

10 Before: After: Notes: Before: After: Notes: Before: After: Notes: Before: After: Notes: Before: After: Notes:

11 Kitchen Questionnaire Name: Date: Circle all that apply: 1: Which of these items do you have in your kitchen? good set of pots and pans good set of knives spatula blender scale for food measurements take-out containers small cooler for carrying meals food processor 2: Which of these items are in your pantry? whole oats quinoa mixed nuts nut butter beans extra virgin olive oil vinegar canned tomatoes spices 3: Which of these items are in your fridge/freezer? beef chicken fish eggs cheese (not spreadable/slices) 4 or more types of fruit 5 or more types of vegetables sweet potatoes 4: Which of the following do you have in your kitchen? chips (potato/corn/vegetable)

12 fruit/granola bars cookies crackers boxed food items (cake mix, instant potatoes, pre-boxed pasta meals etc.) chocolate/candy pop peanut butter (excludes all natural) bread crumbs, croutons, dried bread products at least four types of alcohol 5: Which of the following do you have in your fridge/freezer? at least four types of sauces processed meats (sausage, hot dogs, lunch meat etc.) margarine fruit juices pop baked goods frozen dinners bread/bagels take-out/restaurant meals (includes leftovers) mashed potatoes/cooked pasta/macaroni 6: do you have bowls of candy, chips, crackers, snacks sitting around the house? 7: When you have guests (parties, dinner guests), do you serve them what you think they'll want or what you think is healthy? what is healthy what I think they want 8: When food shopping, do you buy economy bags or smaller sized portions? More than half the time economy sized bags More than half the time smaller sized portions 9: How often do you shop for groceries? fewer than three times a month about once a week more than once a week

13 10: do you keep food in plain view around the house? 11: Do you think healthy eating means low-fat eating? 12: If asked about a certain food item, would you know if it was mainly carbohydrate, protein or fat? 13: When you prepare meals from recipe books, do you use those that contain healthy recipes? most of the time about half of the time almost never 14: Do you prepare meals in advance to take to work, day trips or vacations?, always more than half the time less than half the time almost never 15: Do you hesitate to throw out leftovers or food that was given to you that doesn't fit into your nutrition plan?, I don't like to throw out food No, half the time I throw it out No, I always throw it out

14 Social Support Questionnaire Name: Date: 1: Do the people you spend the most time with each day (people at work/school, family/friends) have healthy habits (exercise regularly, watch what they eat etc.)?, most of them half and half, most don't 2: Does your significant other have healthy habits? doesn't apply 3: Is it easy to find someone to join you in physical activity (workout, hike etc.)?, it's pretty easy, but it's infrequent, it's tough 4: Are treats like doughnuts, cookies and snacks regularly brought to work?, often, but I rarely eat them, never 5: If you eat out more than once per week, do the people you go with usually order healthy options?, always about half the time, never 6: Do you belong to any clubs/groups/sports teams that meet at least twice a week for physical activity, not including a gym membership?, for years, for 6 mos. or less 7: Do you have a gym membership AND attend at least 3 times per week?, for over 1 year

15 , for less than a year, 8: When talking about your nutrition/performance goals with your friends/family how do they respond? they're interested t interested they think I'm crazy 9: Do the people you live with bring home foods considered unhealthy? always sometimes never 10: Do the people you live with bring home foods considered healthy? always sometimes never 11: Do the people you live with and work with schedule things for you that interfere with your planned workout routine? always, this time is not respected sometimes, they didn t think about it never, they respect this time 12: Do those around you bring you information to stay informed on nutrition, exercise etc? always sometimes never

16 Readiness for Change Questionnaire Name: Date: 1: Do you look in the mirror and feel frustrated, upset or embarrassed because of how you look? t sure 2: When you feel tired or run down, what do you think is the cause? getting older my lifestyle something else 3: Are you on medications for heart disease, high blood pressure, type II diabetes?, two or more, one of these 4: Has your fitness deteriorated over the years? If yes, how would you explain that if your habits have stayed the same? family history I'm less active a natural part of aging I'm not sure why 5: If you don't currently have a workout partner, are you willing to find one? 6: Are you willing to join a gym? 7: If you were told that to meet your goals, you needed to throw out the food in your house and shop for different foods, would you? 8: If credible information is presented that contradicts what you currently believe about food and exercise, what will you do?

17 keep an open mind/willing to try it ask a friend ignore it 9: Are you willing to set aside time to discuss with your family and friends to share your behaviour goals and desired outcome?, right away, but in the future 10: If your workplace is your biggest obstacle, would you think about talking to your employer to improve the environment? Would you consider finding new employment? 11: Are you ready to spend less time with people who won't support your goals, and more time with people who do? 12: Can you accept responsibility for the way your body is right now, and understand that while old habits don't make you a bad person, they need to be changed? 13: If someone important to you says that you don't have what it takes to become fit because you've tried and failed before (or any other reason), what will you say? I can do it I know I need to make changes, but I'll take it one day at a time you're right, maybe I can't 14: Are you willing to wake up a bit earlier or stay up a bit later to reach your goals? 15: Are you willing to work up (gradually) to 5 hours of physical activity a week?

18 FOOD, LIQUID, AND ACTIVITY Breakfast Portion Size Time Hunger Level Before (1-5) Energy Level After (1-5) Lunch Portion Size Time Hunger Level Before (1-5) Energy Level After (1-5) Dinner Portion Size Time Hunger Level Before (1-5) Energy Level After (1-5) Snacks Portion Size Time Hunger Level Before (1-5) Energy Level After (1-5) DATE:

19 FOOD, LIQUID, AND ACTIVITY Supplements Dosage Time Physical Activity Time Duration DATE: