Complete Pathway - Personal Training
Port St Lucie Florida & surrounding areas
Training for Golf
Supplements & Oils
Weight Loss Health Assessment
WEIGHT ASSESMENT FORM:
Scheduled Start Date:
Date of Birth:
Your Current Weight:
Your Goal Weight:
Check all that apply:
High Blood Pressure
Please list any other health conditions or special dietary requirements:
Do you drink caffine?
Explain a typical days caffine intake, including coffee, teas and sodas.
Such as , I drink 2 cups of coffee a day with creamer and sugar. I drink a diet coke with lunch...
I do not smoke
I smoke less then a pack per day
I smoke a pack per day
I smoke more then a pack per day
I do not drink
I drink less then once a month
I drink once a month
I drink twice a month
I drink once a week
I drink more then once a week
I drink daily
List a few of your favorite meals, Breakfast, Lunch and Dinner:
What do you feel is your biggest obsticle to losing weight?
Downloads to Complete:
1.) Tracking form to calculate daily expenditure
2.) Weight Loss Agreement
Steve Ruby, CPT, FNS, CES, WLS, WFS ~ Port St Lucie, Florida 34953 ~ 410-588-7780