* Required Field
* Required Field
*
 Last name
*
 First name:
Work  Phone
Home Phone
*
State
Address 1
Zip
Address 2
*
 City
*
E-mail
In case of Emergency call:
*
*
Name
 Number
Gender
Female
Male
Height
inches
FT.
Birth Date:mm/dd/year
Weight
Weekly Exercise Information
Explain in detail what type of resistance exercises, cardiovascular or sports activities you
perform on average during a 7-day period.



Exercise/Activity                             Days/week                                  Duration
Lifestyle / Professional Activity

How would you rate the activity level of your profession, or what you do during the day
(non-exercise related).
Sedentary
Moderately active
Active
Very Active
What are your goals?
Weight Loss
Maintain /Improve Eating Habits
Gain Weight
What is your goal weight?
Which best describes you?
sedentary adult
exercising adult
competitive athlete
growing teenage athlete
adult building muscle
athlete restricting calories
Body Type
Which of the following statements best describes you?
I can eat practically anything I want and I do not gain weight.
I find it very hard to gain weight
I can lose or gain weight by adjusting my activity level and eating habits.
I find it difficult to lose weight.
I can gain weight easily and have to watch what I eat.
Health & Medical Conditions
Check any that apply or describe any other(s).
heart disease
anemia
hypoglycemia
liver disease
kidney disease
diabetes
pancreatic disease
lactation
hypertension
other
Please describe
Make a list of your favorite foods.
Make a list of foods that you dislike.
What time do you normally wake up?
What time do you normally go to bed at night?
If you smoke, how many per day?
If you smoke, how many years have you smoked?
If you drink alcoholic beverages, what and how many per day?
Are you allergic to any types or kinds of foods?
Have you ever been placed on any type of nutritional program in the past?
yes
no
If yes, by whom and what did it consist of? Please explain below.
What were your results?
Have you ever had your body fat tested?
yes
no
If yes, how was it tested and when?
Please list below everything you eat in one 24 hour period. Be
sure to include snacks and beverages, including water. Also,
show approximate amounts.
Time:
Food/Beverage
Time:
Food/Beverage
Food/Beverage
Time:
Food/Beverage
Time:
Food/Beverage
Time: