Medical Appraisal

02

Understanding your medical background will help us customize your program better in consideration of your existing health condition.

MEDICAL APPRAISAL

Reference No.

1. List down any medical conditions you may have.*

2. List down your family’s history of medical conditions.*

3. Did you have any injuries before?*

Yes

4. If yes, list them down below and their causes.

5. Were you seen by a Physical Therapist for your injury?*

Yes

MEDICAL APPRAISAL

6. If yes, how were you treated?

7. Are you currently taking any over-the-counter medications?*

Yes

8. If yes, what medications are you taking?

9. On a scale from 1-10, how would you rate your current health? (1 being awful and 10 being excellent)

03

Strength Appraisal

Assessing your current practices and condition regarding your physical strength can help us apply the best combination of different exercise modalities in your program.

STRENGTH APPRAISAL

1. How many hours a week do you exercise?*

Fewer than 5

5 to 9

10 to 14

15 to 19

More than 20

2. What type of exercises do you engage in?*

3. On a scale of 1 to 10, how would describe your physical energy on an average day? (1 being exhausted and 10 being active)

4. What does strength mean to you?*

STRENGTH APPRAISAL

5. On a scale of 1 to 10, how would you rate how strong you feel today? (1 being weak and 10 being extreme)

6. Have you ever done Strength Training before?*

Yes

7. If yes, what type of Strength Training have you engaged in?

8. How often do you engage in Strength Training per week?*

I don’t do Strength Training

Every day

Less than 5 times

More than 5 times

04

Cardiovascular Appraisal

Finding out the extent of your cardiovascular limit will allow us to maximize your potential for improving your performance with your program.

CARDIOVASCULAR APPRAISAL

1. What does Cardiovascular Fitness mean to you?*

2. Have you ever done Cardiovascular Training before?*

Yes

3. If yes, what type of Cardiovascular Training have you engaged in?

4. How often do you engage in Cardiovascular Training per week?*

I don’t do Cardiovascular Training

Every day

Less than 5 times

More than 5 times

05

Nutritional Appraisal

Adjustments to your diet should be done with enough understanding of your current preferences and previous experiences as well.

NUTRITIONAL APPRAISAL

1. Who lives with you? Check all that apply.*

Spouse or Partner

Roomate(s)

Kid(s)

Pet(s)

Other family members

2. Who does most of the grocery shopping or meal preparation in your household?*

3. Do you have any known food allergies and intolerances?*

Yes

4. If yes, please indicate your allergies and intolerances.

5. On a scale of 1 to 10, how would you describe your normal hunger or appetite? (1 being poor and 10 being amazing)”

NUTRITIONAL APPRAISAL

6. Describe your daily meal plan, from first meal to the last, including the snacks. Please be as detailed as possible.*

7. How often do you eat out in a week?*

I don’t eat out

Every day

Less than 5 times

More than 5 times

8. How often do you prepare meals at home in a week?*

I don’t prepare meals at home

Every day

Less than 5 times

More than 5 times

9. On a scale of 1-10, how would you rate your current nutrition habits? (1 being awful and 10 being excellent)

10. On a scale of 1 to 10, how would you rate your body composition? (1 being horrible and 10 being awesome)

NUTRITIONAL APPRAISAL

11. Right now, are you following any of these diets:*

Low Carb

Paleo

Keto

Vegan

Intermittent Fasting

Calorie Restriction

Other(s)

12. Explain how you follow the diet you previously answered.*

13. On a scale of 1 to 10, how consistent are you with your eating habits? (1 being inconsistent and 10 being exceptional)

14. How much caffeine do you consume on a daily basis?*

1-2 cups

2-3 cups

3-4 cups

4+ cups

15. Do you consume alcohol?

Yes

NUTRITIONAL APPRAISAL

16. How much alcohol do you consume daily?*

17. How much alcohol do you consume weekly?*

18. How much water do you drink per day?

1-2 glasses

2-3 glasses

3-4 glasses

4-5 glasses

5+ glasses

07

Recovery Appraisal

Rest is an important part of your improvement, and scheduling it in your program that matches your lifestyle will assure that you get the recovery you need.

RECOVERY APPRAISAL

1. On average, how many hours do you sleep a night?*

4 hours or less

5 to 6 hours

6 to 7 hours

7 to 8 hours

9 hours or more

2. On a scale of 1 to 10, how would you rate your quality of sleep? (1 being terrible and 10 being amazing)

3. On a scale of 1 to 10, how would you rate your overall recovery? (1 being horrible and 10 being awesome)

4. What does Recovery mean to you?*

RECOVERY APPRAISAL

5. Have you ever tried any Recovery Practices before?*

Yes

6. If yes, what modality or modalities did you use?

7. How often do you engage in Recovery Practices per week?*

I don’t do Recovery Practices

Every day

Less than 5 times

More than 5 times

07

Mindset Appraisal

Your mental health condition is an important aspect in living a well-balanced life, and that is included in the preparation of your program.

MINDSET APPRAISAL

1. On a scale from 1-10, how would you rate your work life balance? (1 being chaotic and 10 being sensible)

2. What is your occupation?*

3. How many hours do you work per week?*

4. On a scale of 1 to 10, how would you rate your daily stress level (1 being relaxed and 10 being upsetting)

5. How do you cope with Stress?*

MINDSET APPRAISAL

6. On a scale of 1 to 10, how ready are you to change your behaviors and habits? (1 being hesitant and 10 being willing)

7. How would you define Mindset?*

8. On a scale of 1 to 10, how mentally “sharp” do you feel on an average day? (1 being dull and 10 being outstanding)

9. What does Mindset mean to you?*

10. Would you tend to have a Fixed Mindset (one thought process for an extended period of time) or a Growth Mindset (open to new ideas and suggestions)?*

Fixed

Growth

MINDSET APPRAISAL

11. Have you ever tried any Mindset Practices before?*

Yes

12. If yes, what Mindset Practices did you engage in?

13. How often do you engage in Mindset Practices per week?*

I don’t do Mindset Practices

Every day

Less than 5 times

More than 5 times

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