Thank you for expressing interest in learning more about how Roc Shabazz can help you achieve your fitness goals and develop healthier lifestyle habits necessary for permanent change in your life.It is important to note that he reserves the right to be selective when considering our clientele. IFBB Pro Roc Shabazz and his team, require completion of a detailed questionnaire and an in-depth consultation/assessment with all prospective clients. The cost for the initial consultation is $100 this does not reflect the cost of your blood panels and payment is due, before your appointment can be booked on the schedule. The consultation is a minimum one (1) hour in-depth appointment with Roc. The length of the consultation depends on various factors, including the nature of your questions. During your appointment, Roc will discuss your goals,perform a general assessment of your physical condition and needs, and create a strategic plan to get you started in achieving those goals. Although you will not do any extraneous physical activity during the consultation, PLEASE WEAR A PAIR OF SHORTS, along with a sports bra for ladies, so that we may take photos and measurements of your current physical state.Please be advised, that while Roc does welcome the opportunity for consultations remotely, via Skype or telephone, this service is strictly for those who do not reside in the Atlanta Metro area and are receiving online services; therefore, it is required that you make an in-person visit to our office, in order to receive full services(i.e. workouts, meal plans, other fitness advice) and complete the official intake process. Roc looks forward to meeting you and thank you for taking the first step.
How did You Hear About Us:
Name and Phone Number
Personal Routine Information
What are your goals?:
What is your daily routine? (workday vs.non-workday) Also, please include the number of hours you work per week.
Do you live with anyone?
Number of Children? (If applicable, please list their ages)
What did you eat and drink the past 48 hours?(Please list times and be specific about amounts per serving)
Are you currently on a cardiovascular program? (Please list training days and type of class if taken)
Are you currently on a weight training program? If so, what type of activity and how often?
Please check all that apply:
High Blood Pressure
Frequent Urinary Tract Infections
Sexually Transmitted Infections
Anxiety or Panic Disorder
Posttraumatic Stress Disorder
Alcohol or Substance Use Problem
Please check any of the following symptoms that you have recently experienced or are of a concern to you.
recent weight loss
recent weight gain
changes in appetite
hair or nail change
Mouth and Throat:
Frequent Sore Throat
Shortness of Breath
Coughing up Blood
Swelling of Feet
Shortness of Breath
Heartburn or Gas
Jaundice (skin or whites of eyes turning yellow)
Blood in Urine
Difficulty not Urinating
Waking up several times at night to go to the bathroom
Leg Cramps While Walking
Tingling in hands or feet
Changes in Memory
Easy Bruising or Bleeding
Heat or Cold Intolerance
Do you experience Chronic Pain?
If you answered yes to experiencing chronic pain How are you managing it now?( Physical Therapy, Medication etc)
Has a Physician ever told you not to exercise?
Do you drink? if so how often?
Do you smoke? If so, how often?
Please list any surgeries or reasons for hospitalization and dates.
Are you Pregnant
Please list any prescription drugs you are taking.
Please list any non-prescription drugs you are taking (vitamins, aspirin, etc.)
Is there any history of heart disease, diabetes or high blood pressure in your immediate family, if so, who?
What is the heaviest you have ever weighed and how long did you weigh that amount? (Exclude pregnancy)
Do you follow a special diet? If YES, please check all that apply.
Have you ever binged, purged, or restricted your food intake? If YES, please describe.
What concerns, if any, do you have about your eating practices?
On a typical day, how many cups of caffeine containing beverages (coffee, tea, soda, energy drinks, etc.) do you have?
Please list any food allergies or foods you dislike.
This Information is not shared or sold. It is utilized by The Roc Shabazz Only.
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