Health Assessment Form - Vegan Fitness Model

PERSONAL DETAILS

Surname:*

Given Names:*

MR/MRS/MS/MISS*

Address:*

Suburb/Town:*

State:*

Country:*

Postcode:*

Are You Male or Female?*

Email:*

Facebook Name:

My Fitness Pal Name:

D.O.B:*

Occupation:*

Height (cm):*

Weight (kg):*

Body Fat%:*

Measurements:

Arms:*

Waist:*

Chest:*

Hips:*

Upper Leg:*

MEDICAL HISTORY

How long since your last medical check?*

Are you taking any prescribed medication?*

Yes
No

If yes, please list or discuss.

Have you had any major injuries/surgery during the last three years?*

Yes
No

If yes, provide details.

Are you, or could you be pregnant or have you given birth in the past 12 months?*

Yes
No

If yes, provide details.

Do have any disorders, diseases or conditions that I need to be aware of?*

Yes
No

If yes, provide details.

Have you ever suffered from any of the following

Asthma or breathing difficulties*

Yes
No

Details

Pain/tightness in the chest*

Yes
No

Details

High or Low blood pressure*

Yes
No

Details

High cholesterol/triglycerides*

Yes
No

Details

Rheumatic fever*

Yes
No

Details

Any heart/stroke condition*

Yes
No

Details

Dizziness*

Yes
No

Details

Diabetes*

Yes
No

Details

Arthritis/joint pain*

Yes
No

Details

Liver/kidney condition*

Yes
No

Details

Muscular pain*

Yes
No

Details

Lower back pain*

Yes
No

Details

Hernia*

Yes
No

Details

Cramps*

Yes
No

Details

Circulation Problems*

Yes
No

Details

Vertigo*

Yes
No

Details

EATING HABITS & LIFESTYLE

Do you consider your diet to be*

Do you know your current macros and calories you consume?*

Yes
No

If yes, please state approximate amounts below.

Is your current food intake causing weight gain?*

Yes
No

 If yes, please describe below.

Do you have bad habits, of yo-yo dieting, food restriction/binge eating?*

Yes
No

If yes, provide details

Do you have or have in the past suffered from any eating disorders?*

Yes
No

If yes, provide details

How do you feel, by the way you currently eat? Example: Loads of energy, weak, fatigued, bloated etc. Please describe.*

Have you used My Fitness Pal or any online food tracking apps? Is so please list which ones.*

Do you suffer from, food intolerances or digestion/gut issues?*

Yes
No

 If yes, please describe below.

Please list all food dislikes, likes and intolerances below? (up to 500 words)*

How many meals per day do you consume?*

Do you over eat at meal times?*

Yes
No
Sometimes

If yes, provide details

Do you take supplements? If so, which ones and quantities?

How many glasses of water do you consume approx. daily? (1 glass = 250mls)*

How do you rate your stress level?*

HIGH
MODERATE
LOW

Do you smoke?*

Yes
No

If YES, how many per day?

Do you drink alcohol?*

Never
Daily
Weekly
Special occasions

Are you currently vegetarian or vegan?*

Yes
No

If yes, how long. If not currently Vegan, what has made you want to transition? Please describe below.

EXERCISE BACKGROUND

What type of physical activity is required at work or throughout a normal day? Please select.*

Sedentary (Desk Job)
Moderately Active (Partially Desk Job, teacher)
Fairly Active (Retail type work, nurse, carer, hospitality etc)
Very Active (Trainer, instructor, trade, on feet all day)
Athletic (Construction, sports coach/teacher, pro-athlete)

Would you describe your lifestyle as? Please select.*

How long since you have participated in regular exercise?*

12 months
6 months
3 months
Currently exercising

How often do you currently exercise per week?*

How many times a week, can you or would you like to participate in an exercise activity?*

What type of activities are you currently doing, or do you usually participate in? Please list. (Up to 500 words)*

What time of the day do you normally train/exercise?*

AM
PM

What times of the days are you available to train/exercise? Please describe.*

How long does your training/exercise sessions normally go for? Please describe.*

Are there any exercises you cannot do, due to injury or for any other reason? Please list.*

Do you have a gym membership or access to an exercise facility? If so, is it indoor or outdoors?*

Do you have a personal trainer? If so, how many days?*

Please detail what exercise equipment you have access too? If yes, provide details.*

Examples: Cable machines, power racks, all-in1 gym, squat racks, barbells, Dumbbells, fit ball, benches, pull-up bar, rings, TRX or Pilate bands, yoga mat, DVDs, kettle bells, ropes, rebounder, cardio equipment (bike, treadmill, stepper etc), outdoor equipment (please specify) or any other type of equipment you can use for exercise?

Are you self motivated and committed?*

Yes
No

GOALS AND OBJECTIVES

In the short-term, what do you want to achieve from this online program and/or meal plan? Please describe.*

What are your long-term lifestyle goals? Please list.*

How many times a week, can you or would you like to participate in an exercise activity?*

Is there any other physical, emotional or other issue’s we need to know about and have not covered above?*

Please upload current photos, if possible.

Upload Front View

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Upload Side View

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Upload Rear View

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Please list your social media accounts, so Crissi can connect on all online platforms, (Facebook, Instagram etc) either by name or copy/past links here.

I certify the above details to be true, please digital sign here >>>*

Date*

Day

Month

Year

Terms & Conditions*

I have read & accept the Terms & Conditions

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Health Assessment Form
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New Health Assessment Form

PERSONAL DETAILS

Measurements:

MEDICAL HISTORY

Have you ever suffered from any of the following

EATING HABITS & LIFESTYLE

EXERCISE BACKGROUND

GOALS AND OBJECTIVES

Please upload current photos, if possible.

I have read & accept the Terms & Conditions

@veganfitnessmodel

Quicklinks

Customer Services

Follow Crissi

Health Assessment FormHome > Health Assessment Form

New Health Assessment Form

PERSONAL DETAILS

Measurements:

MEDICAL HISTORY

Have you ever suffered from any of the following

EATING HABITS & LIFESTYLE

EXERCISE BACKGROUND

GOALS AND OBJECTIVES

Please upload current photos, if possible.

I have read & accept the Terms & Conditions

@veganfitnessmodel

Join our mailing list

Quicklinks

Customer Services

Follow Crissi

Health Assessment Form
Home > Health Assessment Form