eFitness and Diets

** Name:

(Required)

** E-Mail Address:

(Required)

Age:

Current Weight:

Goal Weight:

Current Waist:

Goal Waist:

Height:

Is there a certain date in which you would like to accomplish these goals such as a wedding, photo shoot, vacation:

List everything you currently eat on a normal weekday

Breakfast - Meal 1 + Time:

Meal 2 + Time:

Meal 3 + Time:

Meal 4 + Time:

Meal 5 + Time:

Before Bed - Meal 6 + Time:

What time do you wake up:

What time do you go to bed:

Do you work:

What are your work hours:

Tell me about your job. Do you work in an office or are you on the road:

Look at the list below and tell me how important they are to you: "Not Important", "Important", or "Very Important"

Weight Loss:

Body Fat Loss:

Improve Health:

Muscle Gain:

Toned Muscles:

Strength Gains:

Weight Gain:

Reduce Abdominal Fat:

Develop a Six Pack:

Shredded Body~less than 4% Body Fat:

Increase Energy Levels:

How many times a WEEK do you eat out @ a restaurant:

List all vitamins or supplements you currently take, include brand names:

List all prescribed medications you are taking:

Are you Diabetic:

Tell me about your current health. Do you have any health issues right now:

Have you ever used a protein powdered supplement before:

List any Supplements you currently take:

Have you ever taken a fat loss stimulant like ripped fuel or any supplement that makes your heart rate increase:

How many cups of coffee do you have per day, at what times do you drink coffee, and what do you put in it:

List ANY allergies you have, especially food allergies:

List any foods you dislike, what you really hate to eat:

Please check each food item you will eat:

Chicken Breast:

Lean Steak:

Salmon:

Tuna:

Turkey Breast:

Beef Jerky:

Cottage Cheese:

Egg Whites:

Protein Powder:

Chili:

95% Lean Ground Beef:

Whole Eggs:

Protein Bars:

Carbohydrates

FRESH Vegetables:

Frozen Vegetables:

Plain Quaker Oats Oatmeal:

Apples:

Yams:

Potatoes:

Berries:

Berries, blueberries, strawberries, blackberries, raspberries:

Pineapple:

Healthy Fats:

Nuts:

Flax Seeds:

Extra Virgin Olive Oil:

Flax Oil:

Low Fat Mayo:

To successfully achieve body fat loss you will get a bit run down and fatigued; there is no way around this. I need to know what level of feeling run down are you willing to endure. If your goal is fat loss how much are you willing to sacrifice your energy levels and overall mood to drop the fat?

On a scale of 1~10 {1 being least painful and 10 being the most demanding} if dropping body fat is your main goal, what level would you like to be at:

Do you currently exercise:

If yes, how many minutes total a week:

If you don't currently exercise, how many days a week can you commit to exercising:

What time of day will you work out:

Where do you workout:

If you workout at home, please check the equipment you have:

Dumbbells:

Chin up capability"

Treadmill:

Flat bench:

Power Rack:

Incline Bench:

Cable Unit:

Bike:

Do you have access to a microwave during work hours:

Have you ever injured your lower back, If yes how bad:

List any exercises you can't do because of injuries or nagging pains:

Testosterone Level Test

I have low energy levels:

I am confident:

I feel kind of blah, maybe slightly depressed:

How many hours of sleep do you average a night:

How many total alcohol drinks do you consume in a week:

Do you smoke?:

Please follow this link to my website to calculate estimate of your Body Fat%. Click Here What was your score:

Which type of body would most resemble what you desire:

MEN

		Heavily Muscled, Naturally
		Toned
		Thin, Very Little Muscle

Women

		Muscle
		Toned, curvy, lightly muscled
		Thin, No muscle

Right now what is your current goal you are working on? What do you want to accomplish? Loose fat? Gain Muscle? Tone up? Be Healthy? Improve Blood Lipid Numbers? If you could change your physique what would you want, TALK TO ME: