Advanced Programming & Nutrition Advanced Programming & Nutrition Name* First Last Email* Phone*Age*Height*Weight*List your specific goals* (e.g. amount of weight loss, % of body fat loss or amount of lean muscle gain)Fitness/Strength Training experience:BeginnerIntermediateAdvancedIf you have been exercising on a consistent basis previously, how long ago was this and how long did it last? If you have any diagnosed health conditions, please list. If you are currently on any medication, please list (including contraceptive pill). What additional therapies or interventions are being undertaken for given health problems? Please list any major health concerns. Please list any of your current injuries and previous injuries. What additional therapies or interventions are being undertaken for your old/current injuries? Do you have trouble falling asleep at night?YesNoDo you have difficulty waking in the morning?YesNoDo you sleep less than 8 hours a night?YesNoDo you wake up once or more in the night?YesNoIf you do wake up, what time is it? 1-3am, 3-5am, tired at 5am, many timesDo you sleep in a room with any light or noise?YesNoDo you wake up feeling tired?YesNoDo you wake only with an alarm?YesNoDo you go to bed later than 11pm?YesNoDo you wake up earlier than 6am?YesNoDo you use medication to sleep?YesNoDo you suffer from ingestion or heart burn?YesNoDo you suffer from belching or gas within one hour of eating?YesNoDo you feel tired or sluggish?YesNoDo you feel cold (hands or feet)?YesNoDo you gain weight easily?YesNoDo you have thinning hair or scalp?YesNoDo you have dry hair and/or scalp?YesNoDo you experience mental sluggishness?YesNoDo you experience mental sluggishness?YesNoWhich foods make you uncomfortable when you eat them? (please list)Do you have specific food cravings?Do you have a sense of fullness after meals?YesNoDo you suffer from bloating 1 hour after eating?YesNoDo you suffer from bad breath?YesNoDo you have less than one bowel movement per day?YesNoDo your muscles become easily fatigued?YesNoDo you feel exhausted after moderate exercise?YesNoDo you suffer from any anxiety or nervousness?YesNoDo you smoke?YesNoDo you have an energy dip at 3pm most days?YesNoIf you have any food allergies or aversions, please list them.