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Spectrum Wellness
Info Sheet
Please fill this out to the best of your ability.
Today's Date
First Name
Last Name
City
Postal / Zip code
Region/State/Province
Phone
Email
Height
DOB
Current Weight
Goal Weight
Tell Me About You:
What time do you go to bed?
What time do you wake up?
How many hours of sleep do you get each night? Do you sleep through the night well? Describe your sleep patterns.
If you have any variances in your schedule, please describe below:
Briefly describe your short and long term goals:
What has/is your biggest struggle with maintaining results you have had in the past or actually sticking to a plan? Thing hunger, energy, mood, lifestyle, the plan being unsustainable, lack of discipline, workouts were too long and unatainable, ANYTHING here that helps me know more about you.
What is your occupation? Please indicate what a day is like for you ex. on my feet all day, high stress work environment etc.
What are one or two things that me as a coach can help you be most successful in this process?
Lifting & Cardio
What time of day do you typicall work out?
What gym do you workout at? What kind of a gym is this?
What are your current "splits" ? (Certain body parts on certain days, full body, etc. How many days a week?)
How many days have you lifted in the past month?
What is the duration of your workout?
What kind(s) of cardio have you done in the last month? ex. duration, tempo, how many days a week?.
What cardio/workout/diet regimens have worked for you in the past?
Why were you unable to stick to your weightloss or results you had in the past?
Health History
List any pre-existing health conditions that you have been diagnosed with:
Please provide a detailed explanation, including date of diagnosis:
What issues do your pre-existing health conditions create for you?
Have you ever had organ(s) removed?
If you answered yes please provide date(s) and specify what organ(s)
What is your blood type if known?
Any current or past injuries/limitations? Please provide details:
Are you currently taking any medications, prescribed or over the counter? If so, please list each and provide dosage:
Please list all supplements you are taking, brand, and provide doses. This includes vitamins, protein powders, fiber etc.
Females, please answer the following:
First day of last period:
How many days is a normal cycle for you (the day you get your period is day 1 of your cycle):
Is your cycle normal? If not please explain:
Do you use birth control?
What type of birth control are you using?
Have you had children before? If so, how many, what are their ages, and did you breast feed? If you had a child within the last 2 years and breast fed, please explain how long you breast fed for. (Leave blank or type NA if it's NA)
Do you ever have any undigested food in your stools?
Explain to me your main issues you are having in relation to your hormones and symptoms you are experiencing. (N/A if this doesn't apply to you)
If you have any issues listed above, please explain how long these symptoms have been going on and when they started.
Do your stools float or sink? If unknown, please montior this until we do your phone consult.
Do you have any hair loss, hair breakage, thinning of hair, or brittle nails? If so, please explain:
Explain to me your main issues you are having in relation to your hormones and symptoms you are experiencing:
Do you have any recent lab work from the past 6 months? If so and you are willing to share, please attach below.
Upload File
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Nutrition
Does your schedule allow you to consume meals when needed throughout the day? If you have time restrictions what are they?
How many times a day do you sit to eat an actual meal or snack? This does not include grazing on food randomly but a planned out snack that you do routinely.
Do you snack/graze throughout the day? This would be an unplanned item that you may graze on or instead of eating you may just snack throughout the day. If no just say no, if yes, please explain.
Do you have any food allergies, sensitivities, or food restrictions? If so, what are they?
What kind of caffeine do you consume? How much do you do each day?
How much water do you consume on average each day?
What are your favorite healthy foods from your current diet?
Anything else I may need to know please comment:
Please give me a typical day in what you eat and be as specific as you can. I would like you to give me what meal it is, the time, amount, anything you add to it, or other additional comments.
Additional nutrition info space:
Your Signature
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Full Name
Today's Date
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