Xpress Assessment Short format Xpress Assessment. Once complete, we'll have a brief snapshot and follow-up with you. Date Date Format: MM slash DD slash YYYY First Name:*Last Name:*Email:* A copy of this form will be sent to this email address.Street Address:City:State /Province/Region:Zip/Postal Code:Phone:Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:FemaleMaleHeight (feet)Height (inches)MEDICAL HISTORY: Heart Problems Chest Pain Faint / Dizziness High Blood Pressure Bone / Joint Issues Non-Exercise Age 65+ Diagnosed Hypertension High Cholesterol Smoker Diabetes Family History Heart Disease Chronic Illness / Condition Recent Surgery Pregnant If NO MEDICAL CONDITIONS, please check the box below: NO MEDICAL CONDITIONS GOALS & PREFERENCESBODY COMPOSITION GOAL:MUSCLE GAIN: Increase in lean muscle mass onlyMAINTENANCE: Maintain current body composition, increase fitness levelFAT-LOSS: Reduction in body-fat with slight increase in lean muscle massMENU PREFERENCES:HIGH CARBOHYDRATE: Vegetarian type menu, mostly vegetables, fruits, pastas, rice etc., with smaller portions of meat and dairy productsMIXED: Protein / Carbohydrate - Meat and potato menu, larger meat/dairy servings with substantial carbohydrate , pasta, rice potato servingsHIGH PROTEIN: Carnivore type menu, larger portions of meat fish, poultry and dairy products with smaller portions of carbohydrate, fruit, vegetables, etc.CURRENT CONDITION AND ATTRIBUTESCURRENT ACTIVITY LEVEL:START-UP: De-conditioned, just starting exercise programLIGHTLY ACTIVE: Light exercise or sports 1-3 days per weekACTIVE: Moderate exercise or sports 3-5 days per weekVERY ACTIVE: Hard exercise or sports 6-7 days per weekEXTREMELY ACTIVE: Hard daily exercise or sports (marathon or contest training)Current Weight (lbs):Body-Fat % (blank if unknown):BMR (calories) (blank if unknown):Measurements in Inches (Optional) *RecommendedNeck:Shoulders:Chest:Biceps:Forearms:Waist:Hips:Thighs:Calves:Captcha
