Personal Information
* Required Field
Medical Information

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?

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?

Eating Habits

How many meals do you have each day?

Do you eat breakfast?*

How many alcoholic drinks per week?

What type of alcohol?

How many caffeinated beverages do you drink per day?

How many non-diet 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 eat out often?

If yes, what type of restaurant?

How often?

Do you ever experience the following:
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.

Schedule

When do you eat lunch?

When do you leave work?

When is your morning workout?

When is your evening workout?

General Information

What are your hobbies or recreational activities?

What are your specific goals?

Do you have a refrigerator at work?

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.

PRESENTLY

Body Weight: 

Body Fat% (TBD): 

GOAL

Body Weight: 

Body Fat% (TBD): 

Foods
Select the foods you like
Protein
(Beef & Poultry)
Protein
(Dairy)
Protein
(Legumes)
Carbohydrates
(High Fiber)
Carbohydrates
(Fruits)
Carbohydrates
(High Starch)

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