CLIENT PROFILE QUESTIONNAIRE

CLIENT PROFILE QUESTIONNAIRE

You can fill this form out directly on the computer.Starting with your cursor in the shaded area next to "NAME", begin typing and when finished, tab to next shaded area and repeat. Mark square boxes with an "X" next to the appropriate answare.

Name *

First

Last

Home Phone

Cell Phone *

Email *

Incase of emergency's contact:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GENERAL HEALTH & NUTRITION QUESTIONS

Personal Profile Information

Male
Female

Height

Body fat %

Weight

AGE

Weekly Exercise Information

Explain what type of resistance exercises, cardiovascular or sports activities you perform during an average 7-day period

Exercise/Activity

Days/Weeks/Duration

Lifestyle / Professional Activity

how would you rate the activity level of your profession, or what you do during the day / non exercise related )

Lifestyle / Professional Activity

Sedentary
Moderately
Active
Very Active

Waht are you goals?

Weight loss
Maintain /Improve Eating Habits
Muscular Strength
Muscular Size
Sports Specific
Injury Rehab
Gain Weight
Improve Flexibility

What is your goal weight?

Which best describes you?

Sedentary Adult
Growing Teenage Athlete
Exercising Adult
Adult Building Muscle
Competitive Athlete
Athlete Restricting Calories

Body Type

Which of the following statements best describes you?

I can eat practically anything I want and I don´t gain weight. I find it very hard to gain weight.
I can lose or gain weigh by adjusting my activity level and eating habits.
I can gain weight easily and have to watch what I eat.

FEMALES

Are you periods on times?

Health & Medical Conditions

Mark with an "X" any health conditions listed below that apply to you and describe any other(s) not listed.

Heart disease Diabetes
Arthritis
Headache/Migraine
Persistent Fatigue
Shoulder Problems
Osteoporosis
Anemia
Pancreatic disease
Abnormal chest X-Ray
Low Blood Pressure
Swollen/ Painful Joints
Knee Problems
Leukemia or cancer
Hypoglycemia
lactation
Stroke
Asthma
Foot Problems
Lung Problems
Liver disease
Hypertension
Rheumatic Fever
Kidney Disease
Abnormal EKG
Bursitis
Are you pregnant?
Hernia
Stomach problems
Back Problems
Recently Broken Bones
Emphysema

Any other health problem, concern or issue not mentioned above.Please describe:

Please indicate any medications you are currently taking:

Diuretics
Beta Blockers
Vasodolators
Cholesterol Meds
NSAIDS / Anti Inflammatory ( Motrin, Advil, etc )
Alpha Blockers
Thyroid Meds
Calcium Channel Blockers Diabetes/Insulin
Any other medications for other conditions

Please describe:

What time do you normally wake up?

What time do you normally go to bed at night?

Do you smoke? If so, how many cigarettes per day?

How many years have you smoked?

Do you drink alcoholic beverages?

If so, what type of alcohol and how many drinks per day?

Are you allergic to any types or kinds of foods?

Do you have a history of heart disease?
Do you have a history of metabolic diseases? (Thyroid, liver, renal)
Have you experienced any chest pains?
Have you experienced shortness of breath even during light exercise?
Have you had any problems with dizziness or faintness?
Do you have difficulty breathing while standing?
Do you suffer from sleep apnea (difficulty breathing while sleeping)?
Do you suffer from ankle edema (swelling of the ankles)?
Do you have a known heart murmur?
Have you experienced accelerated heart beat or heart flutters?
Have you experienced severe pain in leg muscles while walking?
Have you been assessed as hypertensive on at least 2 occasions?

What is your average blood pressure?

Has your serum cholesterol been measured at greater than 240 mg/dl? Has your HDL (the "good" cholesterol ) been measured at greater than 60 mg/dl?

Any other medical condition or activity restriction that you may have. It is important that this information be as accurate and complete as possible for your safety and well being. Please describe:

Please list below everything you eat in one 24 hour period. Be sure to include snacks and beverages, including water. Also, show approximate amounts.

Make a list of your favourite foods.

Make a list of foods that you DESLIKE:

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?

If yes, how was it tested and when?

Let’s be Together

22 June

6:30 pm