Health & Lifestyle Assessment

Please complete this questionnaire in full. The more descriptive and accurate that your answers are, the quicker we can provide you with feedback.

* indicates required fields







































Please list your 3 primary goals:








Please record a food diary for three typical days of your diet. Please include one weekend day.








Please record a fitness/workout diary for a typical week. Indicate the day of week and the time of day of each workout.




















Please indicate if you suffer from any of the following (answers to each question are required):


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes





Please indicate if you have ever suffered from any of the following:


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes





Minimal Average Considerable Unbearable


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes


No Yes














No Yes


No Yes





No Yes





No Yes





No Yes








No Yes











No Yes