* Required Field
Home (or Cell) Phone*
Date of Birth*
Do you consider your health to be:
List any present or past illnesses, injuries or conditions and when they initially occurred:*
List any medications (prescribed and/or over the counter) you are currently taking and when you first started taking them:*
Do you exercise regularly?*
If yes, where do you exercise?
What types of exercise and what is the duration and frequency of your exercise sessions?*
What types of exercise equipment do you have at home?*
What times can you exercise throughout the week?*
How many meals do you have each day?*
Do you eat breakfast?*
How many, if any, alcoholic drinks per week?*
What types of alcohol?*
How many caffeinated beverages do you drink per day?
How many sodas do you drink per day?
How many glasses of water do you drink per day?
List any food allergies:*
Do you have an eating disorder?*
Are you a vegetarian?*
If yes, do you consume dairy products?
Do you know how many calories you consume daily?
If yes, how many?
Have you ever weighed your food?
Do you read food labels?
Do you eat out often?
If yes, what types of restaurants?
Do you ever experience the following:
Snacking at night?
Strong or persistant hunger?
Occasional binge eating?
Regaining weight easily?
Craving high-fat or high-sugar foods?
Gaining weight on less food?
Gaining weight after pregnancy or on birth control or estrogen?
The impact of stress on our overall health and well being can't be underestimated. Every day, we face both physical and psychological stress. Some kinds of stress are out of our control; others may be triggers we aren't consciously aware of. Regardless of the source of stress, it must be managed to achieve maximum health and fitness.
Moody / Hard to get along with?
Able to quiet your mind?
Happy and content with life?
Fulfilled and satisfied?
Focused and on task?
Do you sleep well?
How many hours do you sleep per night?
Do you wake up feeling refreshed?
In the last year have you experienced... (check all that apply)
How do you relax? (check all that apply)
When do you wake up?*
When do you arrive at work?*
When do you eat lunch?*
When do you leave work?*
When do you go to bed?*
When is your morning workout?*
When is your morning scheduled break?
When is your evening workout?*
When is your afternoon scheduled break?
What are your hobbies or recreational activities?
What are your specific goals?*
List other goals:
Please fill out only Present Body Weight and Body Fat. You will be contacted by a Dellis Health & Performance representative for goal setting.
Please fill in all required fields
A Dellis representative will get in touch with you shortly