Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Personal Information
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Date of Assessment
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Client Address
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Date of Birth
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Email Address
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Best Contact Number
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How did you hear about My Ultimate Me?
- Internet
- Social Media
- Word of Mouth
- Other
Lifestyle & Fitness
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What is your Fitness Goal?
- To Get Fitter
- Build Muscles
- Lose Weight
- Get Stronger
- Tone Muscles
- Rehab part of my body
- Increase Stamina
- Healthy Nutrition
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Explain the specifics around your fitness goal?
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How soon would you like to achieve this?
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Do you think that lifestyle changes will help achieve your goals?
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What is the best time for you to exercise?
- Mornings (before work)
- Mornings (after school drop off)
- Lunchtime
- Afternoons
- Evenings (after work)
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How do you prefer to exercise?
- Alone
- Group Sessions
- With an Instructor
Medical Assessment
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Do you have any pre-existing medical conditions that would limit your ability to exercise?
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Do you have any specific issues with joints mobility, bones or muscles that we may improve with exercise?
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Are you currently seeing your doctor about any condition that may be affected by exercise? Gives details if yes?
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Detail and current medicines, pills, tablets or natural supplements you are taking currently?
Physical Activity & Nutrition
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Detail any exercise you are doing at the moment?
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What types of exercise do you enjoy the most?
- Walking
- Cycling
- Swimming
- Dancing
- Aerobics
- Yoga
- Boxing
- Running
- Working out in the gym
- Aqua Aerobics
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Any other exercise?
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What types of exercise do you not enjoy?
- Walking
- Cycling
- Swimming
- Dancing
- Aerobics
- Yoga
- Boxing
- Running
- Working out in the gym
- Aqua Aerobics
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How big are the portions normally?
- Small (side plate)
- Medium (bowl)
- Large (dinner plate)
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What foods do you like the most?
- Red Meat
- White Meat
- Fish
- Shellfish
- Green Vegatables
- Potatoes
- Root Vegatables
- Frozen Veg
- Tinned Veg
- Tinned Fish
- Cured meats
- Sausages
- Sweets
- Desserts
- Ice Creams
- Soft Drinks
- Coffee /Tea
- Fruit Yoghurt
- Natural yoghurt
- Cereal
- Bread
- Biscuits -sweet
- Biscuits - savoury
- Nuts
- Seeds
- Low fat crackers
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Would you like to change you eating habits and parts of your lifestyle to assist with reaching your goals?
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Would you like a referral to a nutritionist?
Basic Metrics
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Overweight range BMI
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Obese range BMI
