Global Fitness Coaching

First Name *

Last Name *

Email *

Phone *

Date of birth *

Gender *

Male

Female

Do you currently have or had pains in your shoulders, back, neck, hips, ankles, etc?

How often do you engage in physical activity? *

Is there any reason why you feel you should not do physical activity?

Does your current occupation require any of these?

Long periods of sitting or standing

Long periods of repetitive tasks

Have you had any surgeries? If so, please explain.

What is your current weight? *

What is your height? *

Please list all the vitamins or supplements you are currently taking. Put NONE if does not apply

Please list all prescription or non-prescription medications you are currently taking. Put NONE if does not apply *

Do you have a father, mother, brother, or sister, with issues of diabetes, cancer, heart disease, stroke, etc? *

Yes

Do you frequently have health-related issues like high blood pressure or others with significant risks? *

Yes

Do you develop symptoms upon acute exposure to fragrances, exhaust fumes, or strong odors? *

Do you currently use tobacco products or have you used them in the last 6 months? *

Do you currently drink alcoholic beverages? If Yes, on average how much? *

Do you drink caffeinated products? If Yes, how much? *

If you have any known food allergies or food sensitivities, please list below. *

Do you follow any specific diets or are there specific foods you do not eat. (Ex. Vegetarian no red meat). Put NONE if does not apply.

Do you get fatigued, drowsy, or experience brain fog frequently? *

Have you ever or are you currently taking any hormone medications? *

Check the box if you have a personal history of any of these

What have you tried in the past that did and didn't work? *

What are you currently trying to do to improve your health, if anything? *

On a scale of 1 - 10 (1 not at all, 10 absolutely 100% ready) Is this something that you are ready to start working to improve today? *

Please spend at least a minute to complete your health assessment for us to provide you with an individualized program