First Fitness Gym

By completing this questionnaire, you consent to First Fitness Inc. collecting and using your health information to provide personalized wellness recommendations, exercise plans, and follow-up services. This questionnaire is intended for health screening and wellness purposes and does not provide a medical diagnosis or replace advice from a qualified healthcare professional.

Your Name:

Your Email (Used to Return your Meal Plan):

Your Telephone Number:

Other Telephone:

Your Gender:
MaleFemale

Your Age:

Your Occupation:

Your Address:

Health Assessment Data

Your Blood glucose:

Your Blood Pressure:

Your Occupation:

Your HbA1c:

Your Weight:

Your Height:

Your BMI:

Your Body Fat:

Select your Fitness Goals:
Lose Body FatWeight LossWeight GainMaintain Current WeightImprove My Body's PhysiqueImprove HealthBuild muscleTo Gain StrengthStress ReliefRehabilitation (Recover from Illness)Managing DiseaseImprove Athletic PerformanceIncrease stamina and EndureIncrease Daily Energy Levels

How would you describe your daily activity level?
Sedentary (little to no moving around, work a desk)Light Active (light exercise 1-3 days per week)Moderately Active (moderate 3-5 days of exercise)Very active (6-7days)Extremely active

How Often Do you Exercise?
Multiple Times DailyOnce Daily5+ days/week3–4 days/Week1–2 days/WeekOnce a MonthNever

What type of exercise do you usually do?
Free WeightsFixed ResistanceCardio (Running, Walking Treadmill, Bike, etc.)Group Classes (Spin, Zumba, etc.)Holistic (Yoga, Mobility, Pilate etc.)None

Your Target Weight:

Estimated Body Fat Percentage (If Known):
I don’t knowUnder 15% (Lean)15% – 20% (Fit)21% – 25% (Average)26% – 30% (Above Average)30%+

Daily Activity Level (Outside of the gym):
Sedentary (Desk job, very little movement)Lightly Active (Desk job but I walk around occasionally)Moderately Active (On my feet a lot, e.g., retail, nursing, teaching)Very Active (Physical labor job, e.g., construction, landscaping)

Average Hours of Sleep Per Night:
Under 5 hours5 – 6 hours7 – 8 hours9+ hours

Hydration & Supplementation

Daily Water Intake:
Less than 32 oz (1 Liter)32 oz – 64 oz (1 – 2 Liters)64 oz – 96 oz (2 – 3 Liters)Over 1 Gallon (3.5+ Liters)

Daily Beverages:
Water onlyBlack Coffee / Plain TeaCoffee/Tea with sugar, cream, or flavored syrupsDiet Sodas / Zero-calorie energy drinksRegular Sodas / Sugary DrinksAlcohol (1-2 drinks nightly/often)

Current Supplements:
Creatine MonohydratePre-Workout / CaffeineFish Oil / Omega-3sMultivitaminVitamin AVitamin BVitamin CVitamin DIronMagnesiumZincBCAAs / EAAsProtein powersHerbal supplements

Are you on any medications?:

Would you be willing to Review this Nutrition Service:
YESNO

I consent to submitting my medical data strictly to generate my meal plan:
YES