Health Assessment Complete the following form as truthfully as possible to provide us with information about your current habits and general feeling about health and fitness.Name* First Last Email* Enter Email Confirm Email Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneAge*Height*Weight*Body Fat Percentageif knownDaily Food & Beverage Intake*Please share your typical daily food intake. Be very specific and complete. Include the time and what meals, snacks and beverages were consumed. Include any other items you eat such as candy, gum, etc. What are your current exercise habits?*Primary Fitness / Health Goal*lose weightgain weightgain muscle / improve strengthimprove overall healthreduce / eliminate medicationsMedications & Supplements*Please any medications or supplements you are currently taking, if any. Include over the counter medications like ibuprofen. Does your food or weight feel out of control?*yesnoDo you drink alcoholic beverages?*yesnoHow much do you drink?*How many hours do you sleep?*Do you do shift work?*yesnoHow many times a week or month do you eat out?*Eating Habits*Describe changes, if any, that you have made to your eating habits in the past?Fill in the blanks...To lose weight I need to eat ...*To lose weight I need to workout ...*Rate the following questions using 1 as the lowest and 10 as the highest.Rate how important changing your current health status is to you?*Please enter a value between 1 and 10.Rate how confident you are to make this change at this time.*Please enter a value between 1 and 10.Barriers*What barriers, if any, stand in the way of you achieving your nutritional/health goals? Expectations*What are your expectations after completing 12 weeks and how do you define success?How did you hear about us?*Referral CodeAdditional InformationAny additional information you'd like to share? NameThis field is for validation purposes and should be left unchanged.