All items are required unless otherwise specified.

2-Training and Health Health History

Page 2 of Training Health History Form.

Lifestyle Assessment

What is your day like? Hours worked? Shift work?

Describe.

Describe. What time do you go to bed? Rise?

Are they willing to support you in your new change of lifestyle?

Do you have any hobbies? What is your outlook on life?

Limitations, restrictions, extra information?

Goal Assessment

The reason behind signing up with AllisonEthier.com

Scale of 1-5 with 5 being the most motivated

6 months to a year. If you are not sure you can leave blank.

Nutritional Assessment

Eggs, wheat, gluten intolerance, milk, dairy, nuts

If you have an example of the plan please attach

If you are choosing a nutritional plan option, please provide a 3-day dietary recall.

As an example, you can give me an example of what you would consider a good day, a bad day, and perhaps medium/okay day nutritionally.

if you prefer you can attach 3-day dietary recall, or any nutritional plan that you have followed. In a word, or pdf document. Maximum size 10MB

How much? How often?

Have you ever binged on food? If so, what foods? When?

If on previous nutrition plans, what have you found works well?
What did not work so well with your previous nutritional plans?

What previous coaching styles work best for you?

Your full name.