Your Info
Date
Your Name

Required fields are outlined in red
Gender
    Age
Height
 ft. in.         Weight lbs.
Phone
    Cell     Fax
Address
City
 State    Zip
E-mail
Referred By

Please tell us how you heard about Fire Your Diet—and/or this assessment?
 
Health Questions (12 questions plus disease check-off list)

What are your primary health concerns?

What are your concerns, if any, about body weight?

Have you ever been on a diet? ... ... ... ... Yes No

If yes, which one(s)?

How high is your stress level?

Where is your stress from, how does it affect you?

What are your eating habits? (How many meals, size of meals, what do you typically eat?)

Do you have any other health/heart concerns? ... ... ... ... Yes No

If so, what are they?

What do you do to create balance in your life?

Do you take vitamins or other supplements? ... ... ... ... Yes No

Are you on any medications? ... ... ... ... Yes No

If yes to either question, what are you taking?

What are your health/training goals? What do you want your health to be? What do you want your body to look like?

Are you satisfied with your sex life?   ... ... ... ... Yes No

Do you have sex as often as you want?   ... ... ... ... Yes No

Do you have orgasms as often as you want?   ... ... ... ... Yes No

 

Please check off any condition that applies to you or your family below:

 Condition
You
Your Family
Diabetes
Elevated cholesterol
High triglycerides
High blood pressure
Menopause
PMS
Calcium deficiency
Breast Cancer
Stroke
Heart Attack
Arthritis
Osteoporosis
Frequent colds and flu
Allergies
Asthma
Alzheimer’s
Low Energy
Liver Disease
Kidney Malfunction
Smoker, current, # years?
Former Smoker
Alcohol/Drugs, current, # years?
Former User
Lung Cancer
Colon Cancer
Pancreatic Cancer
Other Cancer, specify