Health & Fitness Questionnaire Health & Fitness Questionnaire Please help me to prepare for your consultation by filling out the questionnaire. Name* First Last Date* Email* Phone*Gender:*FemaleMaleHow did you hear about us? Examples: Google, Yelp, Friend (name), The Pageant Planet, Social Media (Facebook, Instagram)*Have you had any recent blood work (hormones, thyroid, inflammation, vitamins, etc)? If so what were the results?*What is your goal? Do you have a target date and why?*Please describe what has worked for you in the past to reach your fitness goals? What hasn't worked?*What level of activity is your current job?*SedentaryModerately ActiveActiveVery ActiveWhat does your job require you to do?*Sit at a deskSite in your carTravelBe in meetingsOtherCan you pack a lunch?*YesNoThird ChoiceDo you eat breakfast?*YesNoThird ChoiceWhat time of day do you prefer to exercise?*What supplements and medication do you take? (Examples: Vitamin D, B12, Thyroid, Hormones, a muti)*Describe your current weekly exercise routine? Example: Cardio/hiking/running/weights/yoga/walking, how long, and how often.*What beverages do you drink besides water and how frequently? Example: coffee, soda, alcohol, etc*Please list any health concerns or any injuries that I should know about.*Current WeightHeightBirth Date*Is there anything else I should know?I agree to allow Scott Keppel with STS Training Systems to design a weight management program for me to enhance my health and fitness goals. I will follow that program to the best of my ability and I will not hold Scott Keppel or any one related persons or parties personally liable for any problems, illnesses or injuries that might occur due to a sudden change in my nutrition habits. I understand Scott Keppel is not a registered or licensed dietitian, nor a medical practitioner. I have given Scott Keppel all necessary information about myself to prevent any possible complications and realize this should not take the place of any program my own private doctor would suggest.* Yes I agree PhoneThis field is for validation purposes and should be left unchanged.