This is the next step to creating your custom workout & diet plan, and working with me to achieve your goals.

After you complete this form and submit payment for the program you have selected I will have enough information to begin working on your training routine and you will be on your way to results! Please be as detailed as possible, the more information the better able I will be to assist you. I may also request that you email me a picture.

* Full Name

* Address

* City, State , Zip

* Email Address

* Phone number

* Best time to call

* Sex

Male

Female

Personal Statistics & Measurements

* Please take all measurements at the point of widest girth

	Stat
Date of Birth
Height
Weight
Waist
Upper Arms
Shoulders
Chest
Quads
Calves

Goals and Objectives

Please describe your fitness goals in as much detail as possible. Do you plan to compete in bodybuilding, fitness/figure, or another sport? If you want to lose fat, where are your problem areas? If you have multiple goals such as gaining muscle, gaining strength, improving appearance, and improving aerobic capacity, which of your goals are most important to you?

* Goals

Description of Lifestyle

* What is your career

* What type of physical activity does your job require

* What are your regular work hours

* When do you prefer to work out? Mornings or evenings, weekends or weekdays

Current Training Information

* How long have you been training?

* How often do you strength train, and how long is your typical workout?

* How often do you do cardio, and for how long?

* Describe the nature of your weight training in as much detail as possible

Current Diet Information

* How many meals do you eat per day?

* How many cups of water do you drink per day?

* Briefly describe your meals on a typical day. Do you cook or eat out?

* What are some of your favorite foods?

* Do you drink coffee or any other caffinated drink? If so. how many per day?

* Do you drink alcohol? When and how much?

Current Health

* When was the last time you visited a Physician? Do you have any health concerns or chronic injuries? Any limitations on working out that I should be aware of?

Important: Also talk with a Physician before embarking on any exercise or diet program. When following your program if at any point you feel dizzy, sick, nauseaous, faint, sjhortness of breath, chest pain, or any other serious discomfort please stop and consult your Physician. Before taking any recommended supplements read the instructions, cuations, and warnings.

Please double check your answers and make sure you have filled out the form as complete as possible, then click the button below. Copyright Danielle Rouleau.

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