New Client Questionnaire
Questionnaire submission is required for all clients.
Providing detailed answers allows us to better serve you.
We will use this telephone number to contact you directly if necessary.
Include complete street address, city, state and zip code.
Your workout and meal plan will be emailed to this address.
Date of Birth
Select Your Body Type
Naturally Slim: I find it difficult to gain weight.
Weight loss/gain fluctuates with diet & workout program.
Naturally Muscular: Easy muscle gain with a good diet & exercise program.
Husky, Non Athletic: I carry a lot of fat that is difficult to lose.
For example: Sickle-cell trait, Arthritis, High Cholesterol, Gout, Diabetes, Acid Reflux, Tennis Elbow, Heart Problems, Asthma, Osteoporosis, Nerve Damage, High Blood Pressure
If Yes, Please Explain
List ALL surgeries & dates, past medical/health problems AND allergies (medication & food).
Medications (including birth control) & Nutritional Supplements
Include ALL vitamins, dietary & herbal supplements. Indicate 'none' if this category does not apply.
3 Day Food Journal
Be as specific as possible. Remember to include dates, meal times and beverages.
Please List Food Selections That You Prefer Not To Consume
Describe Your Typical Weekly Meals
I prefer variety
I prefer consistency
"I enjoy a variety of meals and don't mind taking time to prepare them daily." - - OR - - "I prefer to reduce preparation time by eating similar meals throughout the week."
Describe Your Weekly Workout Routine
Include cardio (if applicable), weight training and supplemental workouts. List typical start/stop times and days of the week.
What time do you awaken, travel to work, take a lunch break, eat dinner, go to the gym/workout and fall asleep?
Top 5 Fitness Goals
Be as specific as possible and include measurable goals.
Please Indicate Desired Nutrition/Workout Program
Attach Pictures (Rear-Front-Side)
Max file size: 20MB
I understand and agree to the terms of the Austerus FIT Release/Agreement (see below)
Review terms & conditions below.
Click here to upload file
*AUSTERUS FIT RELEASE/AGREEMENT