Client Profile Step 1 of 5 20% Please complete in as much detail as possible. The more I know the better I can personalize the program to suit your lifestyle and personal preferences in order to reach your health and fitness goals! Please Note: All information provided within this profile is completely confidential and will be seen only by the fitness professionals of KY Wellness and Nutrition Consulting. Personal InformationName* First Last Email* Cell PhoneHome PhoneAddress Street Address Address Line 2 City State / Province / Region Postal Code / ZIP AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How Did You Hear About Me? Facebook Instagram YouTube Referral Who Referred You to Me? Client ProfileAge*Height* Weight* Date of Birth Month Day Year Gender* Female Male Do you Smoke? Yes No Do you Drink? Yes No How Often Do you Drink? Once or twice a month Once or twice a week Two or three times a week What time do you normally wake up? What time do you normally go to sleep? What times do you normally eat your meals? What times do you normally eat your snacks? What time do you normally workout? What is your current Occupation? What are your working hours? Time spent walking/standing/doing manual labor? Food ProfileWhat are your current eating habits on a day-to-day basis?Including meal timing, meal frequency, food types, average portions, calories/macros if knownWhat are your favorite healthy foods?What are your favorite “cheat” foods?Do you have any food dislikes or allergies?Do you have any history of disordered eating or binge eating? No Yes Please explain your food disorder history Fitness ProfileWhat is your current workout or training routine?Include style of training, training split, etc.Are you currently incorporating cardio? Yes No How much Cardio? What form? (i.e. steady state, fasted, HIIT)What are your Goals?Check all that apply Health Performance Physical Appearance Or if applicable, expand/explain your GoalsHave you Competed Before? Yes No What division & show are you preparing for?Do you suffer from any health issues or injuries?What gym equipment or home gym materials do you have access to?Anything else you think I should know? AgreementI am entering into a personal training, nutrition and motivation training program with the understanding that I have full responsibility for my own health, physical, mental, emotional, and spiritual well-being. I acknowledge that KY Wellness and Nutrition has not and will not render any medical services or provide any medical diagnosis or advice regarding my physical or medical condition and is not liable for any injuries, distress, or health issues as a result of engaging in the recommended fitness and nutrition programming of KY Wellness and Nutrition. I represent and warrant to KY Wellness and Nutrition that I am in good health, have all necessary medical approval to participate in or use the program and I am otherwise competent and qualified to participate in or use the Program. I agree that if at any time I believe it is unsafe for me to participate in any component of the Program or its activities or to follow its recommendations or advice, I will immediately discontinue my participation or use of the Program. By signing this agreement you are committing to the full length of your program as stated on your checkout cart, there are no allowances for removal from the program before this time has completed. If a payment fails and is not able to be processed within 3 days of payment date a 15% late fee will be charged. I acknowledge that this Agreement is binding and that by agreeing to the above I am aware that all payments are final, non-negotiable and non-refundable after purchase apart from discounts/coupon codes provided by KY Wellness and Nutrition for promotion and refund of initial consultation.Do you Agree with the Above Statement? Yes - I Agree Electronic Signature* To agree with this Agreement please type your full first and last name above. This is considered to be your electronic signature of this Agreement.Today's Date* MM slash DD slash YYYY Note: With all purchases including weekly check ins you are welcome to request dietary changes and variety as needed to a reasonable extent, as long as requests are suitable in terms of dietary choices. All packages purchased are final purchase with no refunds, aside from the initial consultation with the purchase of one of the above program packages. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
