Fill Questionnaire please
First Name
Last Name
Age
Gender
Email
Phone No.
What are your Fitness & Nutrition goals? For example flat tummy, tone body, lose weight, gain weight, Bigger Butt etc. Be as descriptive as possible
What is keeping you from achieving your Fitness & Nutrition goals? (Check all that apply)
Lack of Motivation
Not enough Equipment
Not enough of Time
Lack of Results
Hitting a Plateau
Self Conscious
Not Knowing Where or How to Start
Other
What motivates you? (Check all that apply)
Seeing Results
Having Fun
Praise/Rewards
Feeling Better
Other
Do you follow a current exercise regime? Yes No If yes, please explain.
Are there any physical aspect that limit your participation in exercise?
Are you currently employed? If so, what type of physical activity do you do at work? Heavy lifting sitting, etc..
What activities/exercises do you currently participate in? (Check all that apply)
Running/Walking Aerobics Strength Circuit Biking
Dance
Free Weights
Swimming
Yoga/Pilates
Martial Arts
Sports
Others
Tobacco Use:
I currently smoke
I quit smoking < 6 months ago
I quit smoking over 6 months ago
I never used tobacco
Alcohol Use:
I frequently drink alcohol
I occasionally drink alcohol
I seldom drink alcohol
I never drink alcohol
What is your current activity level?
None
Little (Less than one hour a week)
Moderate (1-5 hours a week)
High (Over 5 hrs. a week)
Do you have any food allergies? Yes/No
How often do you eat out?
Almost Every day
Once a Week
Once a Month
A Few Times a Week
A Few Times a Month
Rarely or Never
Prepare a 3-Day food journal
On average how much sleep do you usually get every night?
How would you describe your current diet? (Vegetarian, Vegan, Paleo etc...)
How much time do you spend sitting or being sedentary during the day?
Do you have any exercise preferences or specific activities you enjoy?
How would you describe your health?
Are you taking any prescription or over-the-counter medications or dietary herbs or any vitamins, minerals, or supplements? Yes/No
Do you have or has your doctor or another licensed healthcare professional told you that you have any of the following conditions?
Allergies
Amenorrhea or absence of menstrual period >3 months
Anemia
Anxiety
Arthritis
Asthma
Cancer
Cardiovascular disease
Celiac disease
Chronic sinus condition
Cigarette smoker
Crohn’s disease
Depression
Diabetes
Disordered eating
Intestinal problems
Gastroesophageal reflux disease (GERD)
High blood pressure/ hypertension
Hyper/hypo-thyroidism
Hypoglycemia
Insomnia
Intestinal problems
Irritable bowel syndrome
Osteoporosis
Polycystic ovary disease Currently pregnant or <3 months postpartum
Surgeries or hospitalization
Past injuries
Describe any other health conditions you have, or for which you take medication?
What would you like to do regarding your weight?
Lose
Maintain
Gain
What is your current weight?
What is your height?
Is there any other information that you think I should know?
Are there any foods that cause you digestive issues?
What foods you will not or would prefer not to eat?
SUBMIT
