FREE ASSESSMENTFORM
This free assessment form will help us out to assess approximately how long it will take to achieve your goals, what
the best program is for you, and how effective the program will be in helping you achieve your goals. Please note that
this assessment is not a promise of obtaining results and is only a general approximation; everyone is different and it
may take less or more time to achieve their desired results. Please type/tick in the grey boxes, save the document and
then email back to info@recalibratedbodies.com. If you have any questions please feel free to ask us.
PersonalDetails
Name: Type Here Age:
Gender:
M
F Weight:
kg Height:
cm Email Address:
Measurements – View at the end of this form where these measurements should be taken exactly on the body
Neck:
cm
Chest (men only):
cm
Waist:
cm
Hips:
cm
Thighs:
cm
Goals
Tick the goals that you want to achieve:
Gain Muscle
Improve Skin Health
Toning
Lose Body Fat
Prepare for a Competition
Improve Diet for Longevity
Increase Fitness
Increase General Health
Increase energy
Other:
Of these goals, rate which are of highest priority:
1.
2.
3.
Is there a specific date that you want your goals achieved before? (eg. Wedding, birthday):
CurrentLifestyle
On a scale of 1 to 5, 5 being extremely high, how stressed are you:
What are your regular sleeping hours? (eg. 10pm-6am):
Do you have difficulty falling asleep?
Yes
No
Do you have difficulty staying asleep?
Yes
List how many cigarettes you smoke per day:
List how much alcohol you consume per week:
CurrentTraining
List your current exercise regime:
Exercise
Eg. Run
Duration
60 minutes
Intensity
Moderate – 10km
List any incidental exercise you perform regularly (eg. Walking to work):
How many times per week can you exercise?
Have long have you been training for?
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Frequency per Week
3 times
No
Do you have access to a gym?
Yes
No
Can if required
CurrentDiet
Fill out the table with what foods and liquids you consumed yesterday, and roughly what times:
Meal
Breakfast
Food and Quantity
Lunch
Dinner
Snacks
Water
Soft Drinks
Alcohol
Coffee/Tea
If you know your current average daily caloric intake and macronutrient breakdown, please tell us:
Calories (Kcal):
Protein (g):
Carbohydrates (g):
Fats (g):
List any stomach discomforts or issues you experience (eg. Bloating, flatulence, IBS):
List any significant food cravings you experience (eg. Salty foods, fatty foods, sweets):
Medical
Tick any medical conditions that you have:
Allergies
Allergenic rhinitis and hay fever
ASDV (Arteriosclerotic vascular
disease)
Blood disorders or anaemia
Cancer, lumps, tumour
Chest tightness, shortness of
breath, asthma
Cold sores and herpes labialise
Common colds, viral infections and
flu
Contusions, bruises, burns and cuts
Colon inflammation and colitis
Chronic pain and fibromyalgia
Calculi and gallstones
Dementia and Alzheimer’s
Diveticula inflammation
(diverticulitis)
Dermatitis, Psoriasis or skin
conditions
Cystitis or urinary track infection
Excess body fat or obesity
Excess alcohol and hangovers
Exhaustion and chronic fatigue
Enteritis or Crohn syndrome
Hypertension or high blood
pressure
Hypo and hyperthyroidism
Insomnia and sleeping disorders
IBS (irritable bowl syndrome)
Insulin resistance or diabetes
Joint problems or arthritis
Lung infection or bronchitis
List any medications you are taking:
List any health conditions or symptoms you have:
List any current injuries:
List any previous serious injuries:
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Low immunity or recurrent
infections
Mood disorders or depression
Migraines or headaches
Menopausal symptoms
Muscle cramping and aches
Otitis and ear infections
Varicose veins
Podagra, gout, elevated uric acid
Pregnant or lactating
Stomach pain, heartburn or
indigestion
Sinus inflammation (sinusitis)
Slow colonic transit or constipation
Stomach ulcers
Thrush, fungal infections or
candida
Have you completed rehabilitation/treatment for these injuries?
Will they limit you in any way?
Write anything else you believe may be of importance to your program(s) and results:
WhatTo Do Now?
Simply email this form back to info@recalibratedbodies.com once completed. From there we’ll perform an
assessment and email you back to let you know approximately how long it will take to achieve your goals, tell you
what the best program choice is for you and how effective one of our programs are in achieving your goals. This will
generally take us 3-4 days to perform, however will let you know as soon as possible!
Whereto Take Your Measurements
Email back to info@recalibratedbodies.com
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