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Personal Information



* Required Field



Zip Code*


Home (or Cell) Phone*

Work Phone

Date of Birth*



Medical Information

Do you consider your health to be:

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:*

Exercise Habits

Do you exercise regularly?*

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?*

What times can you exercise throughout the week
Eating Habits

How many meals do you have each day?*

Do you eat breakfast?*

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?*

Do you have an eating disorder

Are you a vegetarian?*

Are you a vegetarian

If yes, do you consume dairy products?

If yes, do you consume dairy products

Do you know how many calories you consume daily?

Do you know how many calories you consume daily?

If yes, how many?

Have you ever weighed your food?

Have you ever weighed your food

Do you read food labels?

Do you eat out often?

If yes, what types of restaurants?

How often?

Do you ever experience the following:

Regular overeating?

Snacking at night?

Strong or persistant hunger?

Occasional binge eating?

Regaining weight easily?

Eating rapidly?

Craving high-fat or high-sugar foods?

Gaining weight on less food?

Gaining weight after pregnancy or on birth control or estrogen?

Stress Management

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.

Are you...


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)

Sport interests:

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?

General Information

What are your hobbies or recreational activities?

What are your specific goals?*

Specific Goals

List other goals:

Body Composition

Please fill out only Present Body Weight and Body Fat.  You will be contacted by a Dellis Health & Performance representative for goal setting.


Body Weight:* 

Body Fat%: 


Body Weight: 

Please fill in all required fields

A Dellis representative will get in touch with you shortly

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