Contest Prep Program Application Step 1 of 11 9% Name* First Last Email* Enter Email Confirm Email Age*PhoneWhich program are you interested in?*Virginia Beach Contest Prep ProgramOnline Contest Prep Program Have you ever competed before?*YesNoWhat was your placement?What federation did you compete with?Date of Upcoming Competition Medical History and Present Medical ConditionIn order for you to gain the most benefit from this program, we encourage you to answer all of the following questions. If you are uncomfortable with answering a particular question, feel free to leave it blank.Have you have ever had any of the following conditions? Allergies Loss of hearing Asthma Kidney disease Prostatitis Colitis Hepatitis disease Elevated liver enzyme test Pancreatitis Ulcer Heart attack Heart murmur Positive stress test Heart valve abnormality Angina (chest pain) Heart failure High cholesterol High blood pressure Arthritis/rheumatism Loss of consciousness Epilepsy Convulsions/seizures Stroke Diabetes Thyroid trouble Anemia Eczema Cancer (including skin cancer) Sleep Bleeding/bruising easily Enlarged glands Rashes Unexplained lumps Chronic fatigue Night sweats Undesired weight loss Snoring Difficulty sleeping Low blood sugar If you answered YES to any of the above, please explain. Additional Health and Lifestyle QuestionsPlease answer the following questions honestly.Do you occasionally use or are you currently taking any prescription or over-the-counter medications?YesNoIf yes, please list name, dosage, and the reason the medication is used.Have you had any surgical operations in the last 10 years?YesNoPlease explainHas anyone in your immediate family developed heart disease before the age of 60?YesNoDo any diseases run in your family?YesNoPlease explainDo you currently have a cold/cough, or have you had any in the last two weeks?YesNoHave you ever been hospitalized?YesNoIf yes, list date, length of stay, and reasonAre you currently under a doctor’s care?YesNoIf yes, please list what you are being treated for. Are you a current cigarette smoker?YesNoHow many packs of cigarettes do you smoke a day?How long have you been smoking?Are you an ex-smoker?YesNoHow many years did you smoke?How many packs a day?When did you quit?Have you used chewing tobacco or smoked cigars/pipe in the last 15 years?YesNoDo you drink alcohol?YesNoHow many beers do you drink per week?How many ounces of hard liquor do you drink per week?How many ounces of wine do you drink per week? When were your most recent immunizations?TetanusFlu ShotPneumovax When were you most recent health maintenance screening tests?CholesterolResults?PSA (prostate)Results?MammogramResults?SigmoidoscopyResults?Pap SmearResults? Describe any hobbies or recreational activities that have exposed you to noise, chemicals, or dust:Please describe typical weekly exercise or physical activities including any exercise at work:My current diet could be best characterized as (check all that apply): Low-fat Low-carb High-protein Vegetarian/Vegan No special diet Comprehensive Client InformationThis is your comprehensive client information sheet, in which we will ask you to provide some relevant personal information. The answers to these questions are essential in order to allow us to design an optimized individual nutrition program for you. Please answer all questions in the most accurate manner possible while being as concise as possible.Agreement of Terms* I agree Please recognize the fact that it is your responsibility to work directly with your physician before, during, and after seeking fitness consultation. As such, any information provided is not to be followed without the prior approval of your physician. If you choose to use this information without the prior consent of your physician, you are agreeing to accept full responsibility for your decision. Before PhotosYour BEFORE photos* must be in sportsbra/shorts, bikini, or similar. *Upload up to 3 photos. Images too big to upload? Downsize for free here: picresize.com Having trouble uploading your pictures below? Feel free to submit your before photos to email@example.com.Basic InformationHeightWeight (as of this morning) Body compositionPlease provide the following girth measurements (inches or centimetres).NeckChestShoulderBicepsWaistHipsThighCalf Exercise InformationAre you currently exercising regularly (at least 3x per week)?YesNoHow long have you been consistently exercising without a break?Type of exerciseOn the following chart, fill in which type of exercise you normally perform each day: resistance training (RT) interval cardio bouts (INT) low-intensity cardio bouts (LIC) sport-specific work (SSW)MondayTuesdayWednesdayThursdayFridaySaturdaySunday Length of exercisefill in your approximate workout duration for each day (in minutes).MondayTuesdayWednesdayThursdayFridaySaturdaySunday What is your current exercise regimen?If you are not currently exercising regularly, have you ever been on a consistent exercise plan (at least 3x per week)?YesNoIf you have exercised on a consistent basis previously, how long ago was this and how long did it last?Medical and Health InformationIf you have any diagnosed health problems, list the condition(s). If you are on any medications, please list them. What additional therapies or interventions are being undertaken for the given health problem(s)?If you have any injuries, please describe them.Lifestyle InformationWhat do you do for a living?What is the activity level at your job?None (seated work only)Moderate (light activity such as walking)High (heavy labor, very active)Does your job involve shift work?YesNoIf you follow a more regular schedule, do you work…daysafternoonsnightsAre you a primary caregiver for children, individuals with a disability, or an elder relative?YesNoHow often do you travel?RarelyA few times a yearA few time a monthWeeklyDaily SchedulePlease provide your most normal daily schedule listing the time you wake up, work and have breaks, work out and go to sleep.Please describe the physical activities that you participate in outside of the gym and outside of work.Exactly how much money do you spend on groceries per month (provide amounts from your last two grocery bills)?How many times per week do you shop for groceries?How many meals do you eat in restaurants and/or fast food places per week?Exactly how much money do you spend on supplements per month?If you have any known food allergies, please describe them below.Are there any other foods to which you’re particularly sensitive (i.e., which cause excessive gas, bloating, stuffiness, or congestion)?If you’re currently using any nutritional supplements, please list them (as well as the doses you’re taking) below. Miscellaneous InformationIf there is any other information you think might be relevant to your program design, please share it with us below.Please share your most frequent health, nutrition, or physique complaints and/or dissatisfactions with us.Do you have any specific goals?