Application – Linn Mariano Fitness

Name *

First

Last

Date of Birth *

Height *

Weight *

Phone Number *

Email *

Please select training option: *

Online Training
Personal Training

What is your training style? *

How many days per week do you train? *

0 days
1-2 days
3-5 days
5-7 days

Approximately how many steps do you take daily? (Please select one) *

4,000 or less
4,000 - 7,000
7,000 - 10,000
More than 10,000

How many days would you be able to train? *

What type of cardio do you perform and how many minutes per week are you doing? *

Please describe your current diet and/or eating habits. Please include current macros or calories if tracking. *

What are some things you would like to improve? *

Describe your long-term/short-term goal(s)? *

What type of workout equipment do you have available, gym, at home etc? *

What is your current occupation? *

How did you hear about me? *

What are your current stress levels on a scale of 1-10? *

How much water do you typically consume per day? *

Do you consume alcohol? If yes, how many times per week on average? Otherwise type N/A *

Do you consume caffeine? If yes, how much do you consume daily and can you specify what you drink? (ex. energy drinks, coffee, tea). Otherwise type N/A *

Please list all supplements you are currently taking (vitamins, probioties, etc.) *

How many hours do you sleep at night and how would you rate your sleep quality? *

Have you ever/are you currently taking anabolic steroids? *

Yes
No

Are you currently using any form of birth control? If ‘Yes’, please answer the following question. If ‘No’ or ‘N/A’, please proceed to the next section. *

Yes
No
N/A

Which method of birth control are you using? (ex. Birth control pills, IUD, Natural Family planning, etc.) (copy)

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes
No

Do you feel pain in your chest when you perform physical activity? *

Yes
No

In the past month, have you had chest pain when you were not performing any physical activity? *

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes
No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes
No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes
No

Do you know of any other reason why you should not engage in physical activity? *

Yes
No

Does your occupation require extended periods of sitting? *

Yes
No

Does your occupation require extended periods of repetitive movements? (If yes, please explain.) *

Yes
No

Occupation Explanation (type N/A if you selected No above)

Does your occupation require you to wear shoes with a heel (dress shoes)? *

Yes
No

Does your occupation cause you anxiety (mental stress)? *

Yes
No

Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.) *

Yes
No

Recreational Explanation (type N/A if you selected No above) *

Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.) *

Yes
No

Hobbies Explanation (type N/A if you selected No above) *

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (type N/A if not-applicable) *

Have you ever had any surgeries? (If yes, please explain, otherwise type N/A.) *

Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain, otherwise type N/A.) *

Are you currently taking any medication? (If yes, please list, otherwise type N/A.) *

How often do you move your bowels? *

Daily
Weekly

If weekly, how many times per week?

Do you experience bloating? If yes, please elaborate.

Do you have any diagnosed digestion issues, allergies, and/or food sensitivities? (e.g. Celiac Disease, IBS, lactose intolerance, gluten sensitivity, etc)? If yes, please describe.

Do you have regular menstrual cycles? If so, how long are they and are they painful?

Do you have any known hormone issues or conditions like PCOS, Adenomyosis, Endometriosis, Hashimotos, etc? If yes, please elaborate and explain what you are currently doing to manage?

Anything else you want to add that you think may be helpful for me to know?

I verify that all the information above is correct to the best of my knowledge. *

Agree