Complete Patient Intake Form

Client Profile Questionnaire

Date:
Name:
Street Address:
City, State Zip:
Home Phone:
Work Phone:
Mobile Phone:
Email:
Emergency Contact:

General Health and Nutrition Questions

Personal Profile Information

Gender:
Birth Date:
Height:
Weight:
Body Fat%:

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 or Activity Days per 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).

What are your goals?

Weight LossMaintain /Improve Eating HabitsGain Weight

What is your goal weight?

Protein Requirements

Which best describes you?

Sedentary AdultExercising AdultCompetitive AthleteGrowing Teenage AthleteAdult Building MuscleAthlete Restricting Calories

Body Type

Which of the following statements best describes you?

Health & Medical Conditions

Check any that apply or describe any other(s).

Heart DiseaseAnemiaHypoglycemiaLiver DiseaseKidney DiseaseDiabetesPancreatic DiseaseLactationHypertension

Any others?

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?

List any types or kinds of foods that you are allergic to?

Have you ever been placed on any type of nutritional program in the past?
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?

Exercise History

Are you currently involved in a regular exercise program?
Do you regularly walk or run 1 or more miles continuously?
If yes, what is the average number of miles you cover in a workout?
What is your average time per mile in minutes?
Do you practice weightlifting or calisthenics?
Are you involved in an aerobic program?
If yes, what type of aerobic program?

Do you frequently compete in competitive sports?
If yes which one(s)?

GolfVolleyballBowlingFootballTennisBaseballHandballTrackSoccerBasketballWalkingRunningBicycling (outdoors)SwimmingStationary RunningStationary BikingTennisJumping RopeHandballBasketballSquash
List any others?

Average number of times per week?
In which of the following high school or college athletics did you participate?

NoneTrackFootballSwimmingBasketballTennisBaseballWrestlingSoccerGolf
List any others?

Additional Comments:

Patient Health History

Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort:

Head/Neck:
Upper Back:
Shoulder/Clavicle:
Arm/Elbow:
Wrist/Hand:
Lower Back:
Hip/Pelvis:
Thigh/Knee:
Arthritis:
Hernia:
Surgeries:
Other:

Patient Nutrition and Exercise

Are you on any specific food/diet plan at this time?
If yes, please list:

Do you take dietary supplements?
If yes, please list:

Do you experience any frequent weight fluctuations?
Have you experienced a recent weight gain or loss?
If yes, list change:

In what period of time?

How many beverages do you consume per day that contain caffeine?
How would you describe your current nutritional habits?

Other food/nutritional issues you want to include (food allergies, mealtimes, etc.):

Select what best describes your work and exercise habits.
To what degree do you perceive your work environment as stressful?
To what degree do you perceive your home environment as stressful?
Do you work more than 40 hours a week?
Please make any other comments you feel are pertinent to your exercise program.