TEAM EMPOWER CLIENT INQUIRY **Please note that all information provided in this document is 100% confidential. I ask for 100% honesty, so please rest assured that all information given to me is completely confidential**

Please fill this form out in its entirety. Return it to me via e-mail (info@emilyduncanfitness.com) as a Word document or as a PDF file.

Basic Information:Name:E-mail address:Age:Height:Weight:Body Fat % (if you know it):Gender:Occupation (factored into energy expenditure): Training (be as specific as possible):Frequency (# of days per week you currently weight train):  Type of training/current training split (bodybuilding, Olympic weightlifting, Crossfit, powerlifting, triathlon, general, mixed, etc): Duration (on average) per training session:  How long have you been training CONSISTENTLY:   Cardio (be as specific as possible):Frequency (# of days per week you currently do cardiovascular activity): Duration of each session:

Type (HIIT, LISS, MISS): How often are you able to do cardio per week (include number of days per week and duration of each session. Example: 2 days per week for 30 minutes per session)? Other:

Current stress levels on a 1-10 scale, 1 being very little/no stress, and 10 being extremely, overwhelmingly stressed: Have you had blood work done within the last year? Please indicate any important findings or indicate that results were within normal range.  Females only: Do you have a regular menstrual cycle?Are you on birth control or any other hormone modifying medication?Have you ever seen an OB/GYN regarding hormone/menstrual irregularity? Please be specific. 

 What is your current macronutrient split (F/C/P)? If you are on a meal plan, please include a copy of your current plan, including relative quantities of food (example 4oz chicken, 1 cup broccoli, etc) so that I can determine your current intake. PLEASE BE AS SPECIFIC AS POSSIBLE.  Describe what your average daily nutrition routine looks like: Macronutrient preferences in terms of taste/enjoyment (fat vs. carbs vs. protein): Food preferences: How long have you been on your current macronutrient intake/meal plan?  If you follow flexible dieting, how long have you been doing so/what is your experience level? Are you losing, maintaining, or gaining weight on your current program? Describe your dieting history: How many free/untracked meals do you typically eat per week? Please provide a detailed list of any existing and/or pre-existing food allergies, food intolerances, nutrient deficiencies, diseases, etc (ex: lactose intolerance, peanut allergy, anemia, Celiac’s disease…) Have you ever or are you currently dealing with any sort of eating disorder such as anorexia nervosa, bulimia nervosa, or binge eating disorder (BED)? If yes, I am unable to work with you as that’s outside of my scope of practice. I am happy to provide you with professional eating disorder, mental health, etc resources if you wish. Do you have any other serious medical or psychological disorder/disease? Please provide details, including but not limited to age of diagnosis, medications you’re on, necessary lifestyle modifications as a result of your disease, etc.

If you had to list them, what would you say your top five priorities in your life currently are?____________________________________________________________________________________________________ Personal goals (please provide 3-5 body-related goals and 3 non-body related goals):Physical (ex: add mass, reduce body fat, etc):____________________________________________________________________________________________________Non-physical (strength related goals, mental goals, etc):____________________________________________________________________________________________________ What is your reasoning for wanting to work with me as your coach? What are you motivated by?

What is most discouraging to you? What are your biggest strengths (does not have to be fitness related)? What are your biggest weaknesses (does not have to be fitness related)?