Metabolic Fix™ ONE Intake Assessment Step 1 of 8 - Part 1: Client Information 0% Client InformationDate* MM slash DD slash YYYY Name* First Last Email* Please Select Your Coach* Ashley Fillmore Kelly McCall Rebecca Arsena Part 1: General InformationDate of Birth* MM slash DD slash YYYY Age Gender Male Female Non-Binary Please tell me a little bit about yourself?Tell me about yourself and about your current lifestyle. What do you do? What do you enjoy? Provide as much insight into your life as you feel comfortable. Be as specific and as detailed as possible. The better I understand the demands and challenges of your life, along with what motivates and inspires you, the better I can provide a lifestyle plan that helps you achieve success! What are your goals? What do you want to achieve?Goals can be broad or specific. They can include anything from physical body composition changes to health wellness goals, injury remediation, stress reduction, nutritional goals, or general lifestyle improvements. Please be as detailed and specific as possible. Ask yourself, are you happy? If not, what would you like to change?What are your expectations of a health and lifestyle coach?Tell me what you expect from our time together. Are you looking for accountability, encouragement, knowledge, inspiration? Again, be as specific as possible. Part 2: Body CompositionCurrent Height (ft', inches") Current Weight (lbs.) Measurements (in inches", using tape measure)waist*bust/chestr. bicep reg.r. bicep flexr. calve*Measure your waist’s circumference around the belly button. Keep the tape snug but do not indent the skin.**Measure equidistant between knee and hip ***Measure across the widest part of buttocksr. thigh**neckr. wristshoe sizehips*****Measure equidistant between knee and hip ***Measure across the widest part of buttocks How would you describe your current physique in your own words?No asking your significant other to help you with this question. I want to know how you view yourself. Tell me what you think about your body? What are you happy with, and what would you like to change? Do you consider yourself underweight? Overweight? Physically Fit? Be honest with yourself. What are your physical fitness goals?Are you training for a competition? Do you want to lose body fat? Do you want to maintain a healthy weight? What are your physical fitness goals and what are your success criteria? Part 3: Physical ActivityHow often do you perform physical activity per week?Physical activity is defined as everything you do when you aren’t at rest. Its basic movement, with no goal beyond getting from one place to anotherHow often do you exercise per week?Exercise is defined as a movement you do on purpose. It includes sports practice, jogging, yoga, backpacking, swimming, etc. How often do you work-out per week?Workouts are defined as an exercise session that’s deliberately strenuous. You have a goal to work up a sweat, pushing your muscles and circulatory system toward their limit.What type of access to fitness facilities and/or equipment do you have?*Are you a member at a local gym? Do you have gym access through your job or other affiliation? Do you workout at home, and if so what equipment do you have. Please be as detailed as possible.How would you describe physical demand of your primary occupation? High: You are on your feet most of the day and engage in frequent physical exertion. Medium: You are on your feet several times per day. You occasionally engage in physical exertion. Low: You are mostly sedentary during the day and rarely engage in physical activity. Part 4: NutritionDo you consume alcoholic beverages? If so, how often and how many average servings per occasion? Do you use any tobacco products? If so what types and what are the frequencies of use? How would you describe how clean you eat on a daily basis?Eating clean is defined as eating unprocessed foods free of additives and preservatives. Foods that are straight from nature and have not been chemically altered. Do you consume regular, diet, or sugar free soda? If so please describe the type, frequency, and quantities in detail.Do you consume fast-food or equivalents? Do you consume food from fast food restaurants or ready to eat meals? If so please describe the quantities and frequencyHow many meals/snacks do you consume each day? How frequently do you consume food? When do you normally consume it? Please describe your daily eating habits.What do you typically consume for breakfast, lunch, and dinner? Please describe what these three primary meals mean to you. What would you normally consume for each respectively?Are you currently taking any supplements or multi-vitamins? Please describe the type, quantity, and frequency.Do you ever have strong cravings for food? If so what do you crave, and when do you normally crave it. This can be time of day or related to emotions or stress.How many servings of protein, fruit, starches, and vegetables do you consume each day?If you were to break everything you eat in a day down into one of the listed categories, how many times would you consume a serving of each? Educated guesses are fine.How many cups of coffee or caffeinated tea do you consume each day? Please include all cups of both coffee and caffeinated tea. Part 5: Lifestyle & MedicalDo you have a high stress job, or lifestyle? Please try to explain you daily stress level. It is consistently high? If so what are some of the causes for these stressors?How do you cope with daily life stressors? What do you do to deal with stress? How do you manage it? What are things in your life that reduce your level of stress?Do you have trouble falling or staying asleep? How much sleep do you get per night? How would you rate you quality of sleep? Have you identified factors that help or hinder your ability to sleep?Do you have any physical injuries? Are you dealing with any physical injuries that limit or inhibit your mobility? Have you had any serious physical injuries in the past 5 years? Are there any physical conditions or abnormalities that need to be considered?Have you recently experienced or are you currently experiencing any serious health issues? Please be as specific and comprehensive as you feel comfortable. Please describe any current or recent health concerns that should be considered. Part 6: PAR-QHas your doctor ever said that you have a heart condition and that you should only participate in physical activity recommend by a doctor? Yes No Do you feel pain in your chest when you do physical activity? Yes No In the past month, have you had chest pain when you were not doing physical activity? Yes No Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? Yes No Do you know of any other reason why you should not do physical activity? Yes No Do you now, or have you ever had in the past any of the following conditions. If yes, please mark the respective condition with a check and explain in the comments box below. History of heart problems, chest pain or stroke Increased or elevated blood pressure Any chronic illness or condition Difficulty with physical exercise (knee, back, foot problems, etc.) Any surgical procedures within the last twelve months History of breathing or lung problems Muscle, joint, or back disorder, or any previous injury still affecting you Diabetes or thyroid condition Increased blood cholesterol Hernia, or any condition that may be exasperated by strength training Fainting, lightheadedness, blackouts, seizure, or epilepsy Severe or recurrent headaches Eating disorder CommentsPhysician InformationName First Last PhoneEmail Emergency Contact InformationName First Last PhoneRelationship to Client Certification & SignatureCertification* I certify that all information provided on the preceding forms is complete, correct, and accurate. Please type your full legal name as digital signature for the above certification.* Δ
