online training intake

Name *

First Name

Last Name

Phone *

(###)

###

####

What describes you best? *

On hormonal birth control (the pill, patches, IUD, etc)

Not on birth control and have irregular periods

Not on birth control and have regular periods

Peri-menopausal

Post menopausal and no longer have a period

Pregnant/breastfeeding

What describes your periods best? *

I have heavy periods and may even be iron deficient

I have irregular, missing, or very light periods

I have really heavy, painful periods

I have irregular periods that either come more often or rarely

I no longer have a period

Are you a current member of a gym? *

Yes

No

Have you been exercising regularly for the past 6 months? *

Yes

No

In an effort to effectively assist with nutritional planning, some basic health information is asked for within this form. This is voluntary information and you may refuse to fill out certain parts of this form, however, false or incomplete information may pose a threat to your health for which I cannot be responsible. Please feel free to contact me to clarify anything necessary in completing this form. Have you ever been diagnosed with:

Heart Disease

High Blood Pressure

Hypertension

Cancer

HIV/AIDS

Diabetes

Thyroid Disorder

Are you:

Pregnant

On any medications

On any medical restrictions

Receiving medical treatment