Intake Initial Assessment Test Form

    Personal Info

    Birthdate

    Preferred way of contact EmailPhoneText


    Scope of interests

    Check all that apply

    Lose weightLose body fatGain weightGain muscle massMaintain weightImprove physical fitnessHave more energy and vitalityGet in control of you eating habitsGet strongerCompeting for physique or modelingImprove athletic performance


    What do you expect (two part question)

    Part 1What do you expect from us here at BodymetRx?

    Part 2What do you forsee being a challenge for you?


    Habits

    How would you rank your overall eating/nutrition habits right now?

    12345

    1 very poor, 5 excellent

    Do you meet the minimum requirements of exercise through most weeks? 150 minutes of moderate-intensity exercise per week & training each major muscle group 2-3 times a week.

    YesNo

    What type of sports or physical activity do you do?

    How much do the people in your life (work, home, social) support your health, fitness and/or behavior change?

    12345

    1 very poor, 5 excellent


    General Health

    Previous or current significant medical conditions?

    YesNo

    Previous or current significant injurys?

    YesNo

    Current health concerns (illness, pain, injury)?

    YesNo

    Currently taking medication or over-counter prescriptions?

    YesNo

    How would you rank your overall health?


    Disclaimer

    You are responsible to work with healthcare provider before, during and after seeking health & fitness consultation. Information given is not to be followed without prior approval of a doctor. If you chose to use information without full approval, you agree to take full responsibility for your decisions. You also are aware that we are here for help and guidance. Results and meeting expectations fall on you as an individual to put in the work with our help. This is not a magic pill or a get fit quick plan. We are here to inform, help and support you through the journey as you work to become a better version of yourself.
    I agree