The Weight Stops Now

My Transformation from FAT to FIT!

Team Upton Health Form Questionnaire

All potential clients must fill out my health form prior to beginning any program with me.  The more I know about you, the better I can assist you with your nutrition and fitness needs.  Please be as accurate and detailed as possible!  You can copy and paste the questions into an email, or contact me for Microsoft Word and PDF versions of the questionnaire as well. 

 

 


HEALTH QUESTIONNAIRE FORM


Name:

Age:

Height:

Weight:

Body Fat %: (if known)

Any Physical Limitations:

Any Dietary Limitations: (ie: allergy, religious, foods you won't eat, etc)


Any health history I should know: (surgeries, family health history, diagnosed issues, etc)

List any prescribed medications or supplements currently taking: (including vitamins)

How many days per week can you devote to exercise:

What time of day will you be exercising:

List your current diet per day, including meal times: (ie: McDonald’s sausage biscuit, hash browns, small orange juice at 10am, 2 PBJ sandwiches, small bag of chips at 12pm, etc... Please be as specific as possible.)

List your current liquid consumption per day, including times: (ie: 8oz coffee with 5 packets sugar and creamer between 7-9am, 12oz Coke with lunch around 12pm, etc... Please be as specific as possible.)

List your current exercise regimen: (be as detailed as possible)

 

 

What are you current goals:

List all diet or fitness programs you have tried in the past, list your successes or failures with them and explain why:


What you do expect to gain from working with me:

 

 

Any other information you would like me to know:




**Contest Prep Questions***
Have you considered the cost of prepping for a show: (Show fees, food, supplements, tanning, posing suit, makeup, shoes, etc)

Have you ever competed before: (if so, what shows and when)

Are you able to undergo weekly check-ins for pictures, measurements and assessments: (in person or via email/phone calls/texts)